Sabina Case 3 Document Assignment PDF

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Alexis Young Peds Clinical Assignment 4/4/20

Pediatric Case 3: Sabina Vasquez (Core) Documentation Assignments 1. Document your initial focused assessment of Sabina Vasquez. Sabina is having an asthma exacerbation. My focused assessment was the respiratory system, assessing her pulse ox, breath sounds, peak flow, and respiratory rate, effort. 2. Identify and document key nursing diagnoses for Sabina Vasquez. Ineffective airway clearance Knowledge deficit 3. Referring to your feedback log, document the nursing care you provided and Sabina Vasquez’s response.

0:00

You arrived at the child. 0:00

You introduced yourself.

0:05

You washed your hands. To maintain patient safety it is important to wash your hands as soon as you enter the room.

0:10

Child status - ECG: Sinus rhythm. Heart rate: 129. Pulse: Present. Blood pressure: 118/79 mmHg. Respiration: 19. Conscious state: Appropriate. SpO2: 95%. Temp: 36.3 C

1:10

Child status - ECG: Sinus rhythm. Heart rate: 129. Pulse: Present. Blood pressure: 119/80 mmHg. Respiration: 19. Conscious state: Appropriate. SpO2: 95%. Temp: 36.2 C

From vSim for Nursing | Pediatric. © Wolters Kluwer Health.

Alexis Young Peds Clinical Assignment 4/4/20 1:16

You identified the child. To maintain patient safety it is important that you quickly identify the child.

1:25

You identified the relatives. This is important, as the patient is below 18 years of age.

1:37

You asked the parent: Does she have any known allergies? The parent replied: 'No. I don't think so.'

1:58

You attached the <Pulseoximeter>pulse oximeter.<> It is a good idea to monitor the saturation and pulse here. This will allow you to reassess the child continuously.

2:10

Child status - ECG: Sinus rhythm. Heart rate: 129. Pulse: Present. Blood pressure: 118/80 mmHg. Respiration: 19. Conscious state: Appropriate. SpO2: 95%. Temp: 36.2 C

2:11

You measured the <Temperature>temperature<> in the ear. The temperature was 36.2 C.

2:40

You measured the <Bloodpressure>blood pressure<> at 118/80 mmHg. It is appropriate to monitor the child by measuring the blood pressure.

2:48

You looked for normal breathing. She is breathing at 19 breaths per minute. There are a few audible wheezes. The chest is moving equally.

3:10

Child status - ECG: Sinus rhythm. Heart rate: 129. Pulse: Present. Blood pressure: 120/81 mmHg. Respiration: 19. Conscious state:

From vSim for Nursing | Pediatric. © Wolters Kluwer Health.

Alexis Young Peds Clinical Assignment 4/4/20 Appropriate. SpO2: 95%. Temp: 36.2 C 3:22

You listened to the lungs of the child. There are a few audible wheezes. In the clinical situation you should auscultate the lungs both anteriorly and posteriorly.

3:38

You assessed the pain level using the FACES scale. The child answered 0 on the FACES pain scale with a range of 0 to 5.

4:10

Child status - ECG: Sinus rhythm. Heart rate: 129. Pulse: Present. Blood pressure: 119/80 mmHg. Respiration: 19. Conscious state: Appropriate. SpO2: 95%. Temp: 36.2 C

4:26

You checked the pulse at the brachial artery. The pulse is strong, 130 per minute and regular. It is correct to assess the child's vital signs.

4:48

You phoned the provider in order to discuss the patient.

5:10

Child status - ECG: Sinus rhythm. Heart rate: 129. Pulse: Present. Blood pressure: 121/81 mmHg. Respiration: 19. Conscious state: Appropriate. SpO2: 95%. Temp: 36.2 C

6:10

Child status - ECG: Sinus rhythm. Heart rate: 129. Pulse: Present. Blood pressure: 119/80 mmHg. Respiration: 19. Conscious state: Appropriate. SpO2: 95%. Temp: 36.2 C

6:14

You measured the <Peakflow>peak flow.<> The <Peakflow>peak flow<> was 75 L/min. It is a good choice to measure the <Peakflow>peak

From vSim for Nursing | Pediatric. © Wolters Kluwer Health.

Alexis Young Peds Clinical Assignment 4/4/20 flow<> here. The normal peak flow ranges for children aged 5 to 7 years and height 115 to 120 are 175 to 203 L/min for males and 181 to 205 L/min for females. This was indicated and the correct response to the child's condition. 6:27

You turned the oxygen on.

6:27

You placed a 2.5-mg dose of albuterol in a nebulizer. It is important to use the basic rights of medication administration to ensure proper drug therapy. This is part of the correct treatment of asthma.

7:10

Child status - ECG: Sinus rhythm. Heart rate: 130. Pulse: Present. Blood pressure: 117/79 mmHg. Respiration: 19. Conscious state: Appropriate. SpO2: 96%. Temp: 36.2 C

8:10

Child status - ECG: Sinus rhythm. Heart rate: 133. Pulse: Present. Blood pressure: 121/81 mmHg. Respiration: 18. Conscious state: Appropriate. SpO2: 97%. Temp: 36.2 C

9:10

Child status - ECG: Sinus rhythm. Heart rate: 128. Pulse: Present. Blood pressure: 117/79 mmHg. Respiration: 16. Conscious state: Appropriate. SpO2: 98%. Temp: 36.2 C

10:10

Child status - ECG: Sinus rhythm. Heart rate: 124. Pulse: Present. Blood pressure: 119/79 mmHg. Respiration: 15. Conscious state: Appropriate. SpO2: 98%. Temp: 36.2 C

11:10

Child status - ECG: Sinus rhythm. Heart rate: 121. Pulse: Present. Blood pressure: 119/80 mmHg. Respiration: 14. Conscious state:

From vSim for Nursing | Pediatric. © Wolters Kluwer Health.

Alexis Young Peds Clinical Assignment 4/4/20 Appropriate. SpO2: 98%. Temp: 36.2 C 12:10

Child status - ECG: Sinus rhythm. Heart rate: 119. Pulse: Present. Blood pressure: 119/79 mmHg. Respiration: 14. Conscious state: Appropriate. SpO2: 99%. Temp: 36.2 C

13:10

Child status - ECG: Sinus rhythm. Heart rate: 117. Pulse: Present. Blood pressure: 117/78 mmHg. Respiration: 14. Conscious state: Appropriate. SpO2: 99%. Temp: 36.2 C

13:24

You provided education to the relative regarding the child's condition. This is correct. It is important to use every opportunity to provide education.

13:49

You provided patient education. This is correct. It is important to use every opportunity to provide patient education.

14:10

Child status - ECG: Sinus rhythm. Heart rate: 117. Pulse: Present. Blood pressure: 118/79 mmHg. Respiration: 14. Conscious state: Appropriate. SpO2: 99%. Temp: 36.2 C

14:23

You listened to the lungs of the child. The breath sounds are clear and equal bilaterally. In the clinical situation you should auscultate the lungs both anteriorly and posteriorly.

14:30

You looked for normal breathing. She is breathing at 14 breaths per minute. The chest is moving equally.

15:10

Child status - ECG: Sinus rhythm. Heart rate: 116. Pulse: Present. Blood pressure: 118/79 mmHg. Respiration: 13. Conscious state:

From vSim for Nursing | Pediatric. © Wolters Kluwer Health.

Alexis Young Peds Clinical Assignment 4/4/20 Appropriate. SpO2: 99%. Temp: 36.2 C 15:10

You measured the <Bloodpressure>blood pressure<> at 118/78 mmHg.

15:26

You asked the child how she felt. She replied: 'Not too well...'

16:10

Child status - ECG: Sinus rhythm. Heart rate: 116. Pulse: Present. Blood pressure: 120/81 mmHg. Respiration: 13. Conscious state: Appropriate. SpO2: 99%. Temp: 36.2 C

16:27

The nebulized albuterol stopped.

16:57

You measured the <Peakflow>peak flow.<> The <Peakflow>peak flow<> was 170 L/min. It is a good choice to measure the <Peakflow>peak flow<> here. The normal peak flow ranges for children aged 5 to 7 years and height 115 to 120 are 175 to 203 L/min for males and 181 to 205 L/min for females.

17:10

Child status - ECG: Sinus rhythm. Heart rate: 116. Pulse: Present. Blood pressure: 118/79 mmHg. Respiration: 13. Conscious state: Appropriate. SpO2: 99%. Temp: 36.2 C

17:23

You listened to the lungs of the child. The breath sounds are clear and equal bilaterally. In the clinical situation you should auscultate the lungs both anteriorly and posteriorly.

17:30

You looked for normal breathing. She is breathing at 13 breaths per minute. The chest is moving equally.

From vSim for Nursing | Pediatric. © Wolters Kluwer Health.

Alexis Young Peds Clinical Assignment 4/4/20 17:44

You provided education to the relative regarding the child's condition. This is correct. It is important to use every opportunity to provide education.

18:02

You phoned the provider in order to discuss the patient.

18:10

Child status - ECG: Sinus rhythm. Heart rate: 115. Pulse: Present. Blood pressure: 119/80 mmHg. Respiration: 13. Conscious state: Appropriate. SpO2: 98%. Temp: 36.2 C

18:23

A patient handoff was performed. Asthma affects the airways by causing both bronchoconstriction and lower airway swelling, which in turn cause wheezing and/or coughing. Common triggers for asthma include recent upper airway viral infection, animal dander, dust mites, roach droppings, pollens, dust and newspapers, household cleaning chemicals, perfumes, smoking, and poor urban air quality. [newline][newline]Albuterol is a short-acting beta-2 agonist that causes smooth muscle relaxation of the lower airways. Use of an MDI with valved holding chamber (spacer) has been found to be equivalent to nebulizer as far as time to recovery of symptoms, repeat visits, and hospital admissions. Spacers are recommended for any inhaled asthma drug in young children due to the difficulty of using an MDI without a spacer properly and the increased drug deposition. All patients should have an asthma action plan for optimal treatment and to avoid asthma triggers. More information about rescue versus maintenance medications may be found in the NIH asthma guidelines.

From vSim for Nursing | Pediatric. © Wolters Kluwer Health.

Alexis Young Peds Clinical Assignment 4/4/20

4. Document the patient teaching that you would provide for Sabina Vasquez and her family before discharge. I would education her and her family about triggers that can exacerbate asthma and help them identify those triggers. Educate her and family about albuterol purpose, dose, route, side effects, and when and how to take it. Have Sabina and her mother demonstrate to me the proper use of the inhaler and answer any questions. No smoking in the home, she should carry her rescue inhaler at all times, and to use the bronchodilator then the corticosteroid.

From vSim for Nursing | Pediatric. © Wolters Kluwer Health....