Makala Bailey
Sabina Vasquez complex
Documentation
1. Document your initial focused assessment of Sabina Vasquez.
Sabina was having an exacerbation of her asthma. My main focus was to
focus on her respiratory system, pulse ox, breath sounds, and rate and
effort of respirations.
2. Identify and document key nursing diagnoses for Sabina Vasquez.
Ineffective airway clearance
Impaired gas exchange r/t to excess mucous production and carbon
dioxide retention.
3. Referring to your feedback log, document the nursing care you provided and
Sabina Vasquez's response.
Washed hands and introduced myself to the p, ID pt and relative, verified
consent
Asked questions about visit and past
Respiratory focused assessment such as examined chest, auscultated
lungs, pulse ox
Vital signs and pain level
Assessed Iv before giving medications like cefuroxime, azithromycin,
acetaminophen and then provided patient education to both the patient
and relative
Called the provider and got an order to administer albuterol and did so
Provided comfort measures like stuff animal and juice
Provided education again while nebulizer was in effect
Reassessed pain listened to lungs and then did handoff report
4. Document the patient teaching that you would provide for Sabina Vasquez and
her family before discharge.
Educate signs and symptoms of respiratory distress and have her show
the areas of the body and have her describe what she should be looking
for. Educate that medications needs to still be completed even after child
feels better. Avoid triggers to asthma like environments and such that can
make asthma worse, have then demonstrate how the inhaler works and
always make sure you have the prescription filled and beware of the
amount each inhaler has.
Sabina Vasquez complex
Documentation
1. Document your initial focused assessment of Sabina Vasquez.
Sabina was having an exacerbation of her asthma. My main focus was to
focus on her respiratory system, pulse ox, breath sounds, and rate and
effort of respirations.
2. Identify and document key nursing diagnoses for Sabina Vasquez.
Ineffective airway clearance
Impaired gas exchange r/t to excess mucous production and carbon
dioxide retention.
3. Referring to your feedback log, document the nursing care you provided and
Sabina Vasquez's response.
Washed hands and introduced myself to the p, ID pt and relative, verified
consent
Asked questions about visit and past
Respiratory focused assessment such as examined chest, auscultated
lungs, pulse ox
Vital signs and pain level
Assessed Iv before giving medications like cefuroxime, azithromycin,
acetaminophen and then provided patient education to both the patient
and relative
Called the provider and got an order to administer albuterol and did so
Provided comfort measures like stuff animal and juice
Provided education again while nebulizer was in effect
Reassessed pain listened to lungs and then did handoff report
4. Document the patient teaching that you would provide for Sabina Vasquez and
her family before discharge.
Educate signs and symptoms of respiratory distress and have her show
the areas of the body and have her describe what she should be looking
for. Educate that medications needs to still be completed even after child
feels better. Avoid triggers to asthma like environments and such that can
make asthma worse, have then demonstrate how the inhaler works and
always make sure you have the prescription filled and beware of the
amount each inhaler has.
