Sabrina vasquez documentation assignment PDF

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Pediatric Case 2: Sabina Vasquez Documentation Assignments 1. Document your initial focused assessment of Sabina Vasquez. a. During the initial focused assessment, I ausculated the lungs which revealed a small amount of wheezes. Since the patient has been diagnosed with lower right lobe pneumonia the wheezes heard are related to the alveli becoming filled with fluid. During assessment of her vital signs, her SPO2 was 92% on 4L nasal cannula, BP 121/81, HR 145 sinus tachycardia, respirations 28, temperature 39.1c. Due to the patient’s decreased SPO2 the provider was notified and extra orders were placed. An assessment of the IV site was performed and no inflammation or infiltatation was present. b. 2. Identify and document key nursing diagnoses for Sabina Vasquez. c. Impaired gas exchange related to increased secretions and bronchospasm as evidenced by decreased SPO2, increase need for oxygen, wheezes heard on auscultation, pt states “I cant breath”. d. Impaired airway clearence related to increased secreation production as evidenced by non productive cough, decreased SPO2, wheezes heard on auscultation 2. Referring to your feedback log, document the nursing care you provided and Sabina Vasquez’s response. a. Nurse introduced her self, washed hands, identified patient and family members b. The nurse assessed the patient pain level. Patient rated her pain a 1 on the FLACC scale c. The nurse assessed the patients vital signs i. BP- 127/84, HR 146 sinus tachycardia, RR 28, temp 39.1c, SPO2 94% on 4L NC d. Nuse auscultated chest. Wheezes heard, chest movement equal. e. The nurse assessed the patients IV site. The site was dry and intact with no redness, swelling, infiltratation, bleeding, or drainage f. The nurse asked the mom if the patient has any drug allergies. The mom stated “no” g. The nurse administered 240mg of actaminiophen for pain and to reduce fever. Patient tolerated well. h. The nurse administered 190mg of azithromycin by mouth. Paitient tolerated well. i. The nurse started a piggy back infusion of 475mg of cefuroxime IV. Patient tolerated well. j. The nurse phoned the provider to discuss findings k. The nurse administered 2.5mg dose of albuterol in a nebulizer per STAT order l. The nurse provided education to patient and family regarding the patients condition m. The handoff was performed

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

3. Document the patient teaching that you would provide for Sabina Vasquez and her family before discharge. a. The family should be educated on how to correctly administer the medications at home. The family should be able to recognize life threatening side effects of those medications. b. The nurse should educate the patient on what is going on in their body in a way that the child can understand. c. The nurse should educate both the patient and family how to use the incentive spirometer and how to perform deep breathing excerises to help expel secretions.

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