Pediatric Case 2: Sabina Vasquez
Documentation Assignments
1. Document your initial focused assessment of Sabina Vasquez.
Sabina is having an asthma exacerbation. The initial focused assessment is the respiratory
system, assessing her breath sounds, peak flow, and respiratory rate.
2. Identify and document key nursing diagnoses for Sabina Vasquez.
Sabina’s key nursing diagnoses was knowledge deficiency and ineffective airway clearance.
3. Referring to your feedback log, document the nursing care you provided and Sabina Vasquez’s
response.
After introducing myself, washed my hands and identified my client, I assessed her pain level
using the FACES scale. I looked for normal breathing and attached a pulse oximeter on her. I
always checked her current blood pressure using the NIBP measurement cuff. I asked relative if
client had any known allergies to anything and after I administered the medication I measured
her peak flow and after phoned her primary provider. The provider ordered me to administer 2.5
mg dose of albuterol in a nebulizer. I provided education to the client and relative. I then
reassessed the client and handed her off.
4. Document the patient teaching that you would provide for Sabina Vasquez and her family before
discharge.
I would educate the client and her family about triggers that can exacerbate asthma and help
them identify them. Also educating the client and her family about the medication, how to
properly use it, the side effects, routes, dose... etc. I would like to see the client and her relative
demonstrate how they properly use the inhaler and recite information that was just given
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
Documentation Assignments
1. Document your initial focused assessment of Sabina Vasquez.
Sabina is having an asthma exacerbation. The initial focused assessment is the respiratory
system, assessing her breath sounds, peak flow, and respiratory rate.
2. Identify and document key nursing diagnoses for Sabina Vasquez.
Sabina’s key nursing diagnoses was knowledge deficiency and ineffective airway clearance.
3. Referring to your feedback log, document the nursing care you provided and Sabina Vasquez’s
response.
After introducing myself, washed my hands and identified my client, I assessed her pain level
using the FACES scale. I looked for normal breathing and attached a pulse oximeter on her. I
always checked her current blood pressure using the NIBP measurement cuff. I asked relative if
client had any known allergies to anything and after I administered the medication I measured
her peak flow and after phoned her primary provider. The provider ordered me to administer 2.5
mg dose of albuterol in a nebulizer. I provided education to the client and relative. I then
reassessed the client and handed her off.
4. Document the patient teaching that you would provide for Sabina Vasquez and her family before
discharge.
I would educate the client and her family about triggers that can exacerbate asthma and help
them identify them. Also educating the client and her family about the medication, how to
properly use it, the side effects, routes, dose... etc. I would like to see the client and her relative
demonstrate how they properly use the inhaler and recite information that was just given
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
