Pediatric Case 4: Sabina Vasquez (Complex)
Documentation Assignments
1. Document your initial focused assessment of Sabina Vasquez.
A&Ox3, no known allergies, sweating, lethargic, warm to touch, SOB, reduced lung sounds at the right
lung base, audible wheezes, chest moving equally, sinus tachycardia, HR 144 bpm, RR 29 bpm, BP
122/84, SpO2 93%, pain level 1 out of 5 on the FACES scale, IV site showing no signs of REEDA, reports
(out of breath) ‘I can’t breathe’. Her elevated heart rate and dropping SpO2 indicates that I need to call
to the provider.
2. Identify and document key nursing diagnoses for Sabina Vasquez.
- Impaired gas exchange r/t excess mucus production and carbon dioxide retention
- Ineffective airway clearance, ineffective breathing pattern, hyperthermia r/t infection, activity
intolerance, anxiety r/t hypoxia
3. Referring to your feedback log, document the nursing care you provided and Sabina Vasquez’s
response.
a. Upon entering the room I washed my hands, identified the patient and the patients family
member at the bedside, and asked about any known allergies. Patient’s mother replied ‘No, not
that I know of’.
b. Assessed the patients pain level using the FACES scale. Patient answered 1 out of 5.
c. Asked the child how she felt. She responded (out of breath) ‘Not so good’. Asked child why she
was here. She replied ‘I have problems breathing’
d. I attached the pulse oximetry and the automatic NIBP measuring cuff. Patient tolerated well.
e. Assessed patients lung sounds and respirations and temperature. Patient tolerated well.
f. Asked if could look at the patient’s IV site. Patient replied with sense of panic, “Why? Will it
hurt?’ and I reassured her that no, it would not hurt.
g. Provided education to patient and patients relative regarding the child’s condition. Both
responded with ‘Okay’
h. Initiated antibiotic therapy. Started an IV piggyback infusion of 475 mg of cefuroxime IV to treat
the patients pneumonia. Administered a 190 mg dose of azithromycin orally to address the
pneumonia. Administered 240 mg dose of acetaminophen orally to address the patient’s high
fever. Patient tolerated well.
i. Provided patient education and called the provider to report patient’s declining SpO2 and
tachycardia outside of orders normal limits.
From vSim for Nursing | Pediatric. © Wolters Kluwer Health.
This study source was downloaded by 100000832739096 from CourseHero.com on 09-09-2022 04:58:07 GMT -05:00
https://www.coursehero.com/file/58810599/AUPedsCase04-SabinaVasquez-Complex-DApdf/
Documentation Assignments
1. Document your initial focused assessment of Sabina Vasquez.
A&Ox3, no known allergies, sweating, lethargic, warm to touch, SOB, reduced lung sounds at the right
lung base, audible wheezes, chest moving equally, sinus tachycardia, HR 144 bpm, RR 29 bpm, BP
122/84, SpO2 93%, pain level 1 out of 5 on the FACES scale, IV site showing no signs of REEDA, reports
(out of breath) ‘I can’t breathe’. Her elevated heart rate and dropping SpO2 indicates that I need to call
to the provider.
2. Identify and document key nursing diagnoses for Sabina Vasquez.
- Impaired gas exchange r/t excess mucus production and carbon dioxide retention
- Ineffective airway clearance, ineffective breathing pattern, hyperthermia r/t infection, activity
intolerance, anxiety r/t hypoxia
3. Referring to your feedback log, document the nursing care you provided and Sabina Vasquez’s
response.
a. Upon entering the room I washed my hands, identified the patient and the patients family
member at the bedside, and asked about any known allergies. Patient’s mother replied ‘No, not
that I know of’.
b. Assessed the patients pain level using the FACES scale. Patient answered 1 out of 5.
c. Asked the child how she felt. She responded (out of breath) ‘Not so good’. Asked child why she
was here. She replied ‘I have problems breathing’
d. I attached the pulse oximetry and the automatic NIBP measuring cuff. Patient tolerated well.
e. Assessed patients lung sounds and respirations and temperature. Patient tolerated well.
f. Asked if could look at the patient’s IV site. Patient replied with sense of panic, “Why? Will it
hurt?’ and I reassured her that no, it would not hurt.
g. Provided education to patient and patients relative regarding the child’s condition. Both
responded with ‘Okay’
h. Initiated antibiotic therapy. Started an IV piggyback infusion of 475 mg of cefuroxime IV to treat
the patients pneumonia. Administered a 190 mg dose of azithromycin orally to address the
pneumonia. Administered 240 mg dose of acetaminophen orally to address the patient’s high
fever. Patient tolerated well.
i. Provided patient education and called the provider to report patient’s declining SpO2 and
tachycardia outside of orders normal limits.
From vSim for Nursing | Pediatric. © Wolters Kluwer Health.
This study source was downloaded by 100000832739096 from CourseHero.com on 09-09-2022 04:58:07 GMT -05:00
https://www.coursehero.com/file/58810599/AUPedsCase04-SabinaVasquez-Complex-DApdf/
