Pediatric Case 3: Sabina Vasquez (Core)
Documentation Assignments
1. Document your initial focused assessment of Sabina Vasquez.
I assessed Sabina’s breathing patterns and listened to her lungs, found that she
was wheezing and having difficulty breathing. I asked her what she was doing at
the time and spoke to the mom regarding any possible allergens that could have
set off the attack.
2. Identify and document key nursing diagnoses for Sabina Vasquez.
Ineffective breathing pattern R/T asthma AEB difficulty breathing.
Ineffective airway clearance R/T asthma AEB audible wheezing.
3. Referring to your feedback log, document the nursing care you provided and
Sabina Vasquez’s response.
I introduced myself to the patient, washed my hands then identified her and the
adult in the room. I asked Sabina why she was at the hospital, she said she
couldn’t breathe. I asked her what she was doing when it started and if she was in
any pain. She denied any pain and said she was outside playing. I checked with
her mom about any possible allergies or recent allergen exposure and she said
there were none. Her mom said she has been coughing recently. I listened to the
patient’s lungs and heard wheezing. I checked her vitals and offered her a toy
which she was happy to have. I then phoned the doctor for orders. The dr.
ordered a nebulizer treatment and peak flow testing.
4. Document the patient teaching that you would provide for Sabina Vasquez and
her family before discharge.
Sabina should be taking her medication exactly how it is prescribed, even if she
feels like it is under control. She and her family should know now to monitor her
asthma and use a peak flow meter to help keep track. She should also always
carry her rescue inhaler. Her family should be sure to avoid having Sabina be in
contact with any triggers that may aggravate her asthma such as dust, pets and
smoking.
F r o m273v9S09im6 frfoomr CNouurrsseHinegro.|coPmeodnia09tr-
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Documentation Assignments
1. Document your initial focused assessment of Sabina Vasquez.
I assessed Sabina’s breathing patterns and listened to her lungs, found that she
was wheezing and having difficulty breathing. I asked her what she was doing at
the time and spoke to the mom regarding any possible allergens that could have
set off the attack.
2. Identify and document key nursing diagnoses for Sabina Vasquez.
Ineffective breathing pattern R/T asthma AEB difficulty breathing.
Ineffective airway clearance R/T asthma AEB audible wheezing.
3. Referring to your feedback log, document the nursing care you provided and
Sabina Vasquez’s response.
I introduced myself to the patient, washed my hands then identified her and the
adult in the room. I asked Sabina why she was at the hospital, she said she
couldn’t breathe. I asked her what she was doing when it started and if she was in
any pain. She denied any pain and said she was outside playing. I checked with
her mom about any possible allergies or recent allergen exposure and she said
there were none. Her mom said she has been coughing recently. I listened to the
patient’s lungs and heard wheezing. I checked her vitals and offered her a toy
which she was happy to have. I then phoned the doctor for orders. The dr.
ordered a nebulizer treatment and peak flow testing.
4. Document the patient teaching that you would provide for Sabina Vasquez and
her family before discharge.
Sabina should be taking her medication exactly how it is prescribed, even if she
feels like it is under control. She and her family should know now to monitor her
asthma and use a peak flow meter to help keep track. She should also always
carry her rescue inhaler. Her family should be sure to avoid having Sabina be in
contact with any triggers that may aggravate her asthma such as dust, pets and
smoking.
F r o m273v9S09im6 frfoomr CNouurrsseHinegro.|coPmeodnia09tr-
This study source was downloaded by 10000 0 8 3
ic . © W o lt e r s K lu w e r H ealth.
0 9- 2 022 06 :1 7 :4 8 G M T -0 5 :0 0
https://www.coursehero.com/file/38575499/SabinaVasquez1docx/
