*NURSING > CASE STUDY > PEDS 123 Pediatric Case 3 Sabina Vasquez (Core) Documentation Assignments (All)

PEDS 123 Pediatric Case 3 Sabina Vasquez (Core) Documentation Assignments

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1. Document your initial focused assessment of Sabina Vasquez. My initial focused assessment of Sabina Vasquez included assessing her airway and examining her respirations as well as her apical puls... e and blood pressure. I also wanted to assess her pain level with the FACES scale, which indicated that she was having chest pain 2. Identify and document key nursing diagnoses for Sabina Vasquez. Impaired gas exchange related to excess mucous production and carbon dioxide retention, Risk for activity intolerance related to respiratory condition as evidenced by pneumonia, Ineffective airway clearance related to infection as evidence by pneumonia, Ineffective breathing pattern related to pain as evidenced by chest pain, Impaired comfort related to illness-related symptoms as evidenced by dyspnea, risk for electrolyte imbalance related to insufficient fluid volume. 3. Referring to your feedback log, document the nursing care you provided and Sabina Vasquez’s response. Sabina positively responded to the nursing care I provided her with during the simulation experience. I made sure to provide her with a drink since it was advised she drink enough fluids. After taking her temperature and it was 102 degrees Fahrenheit, I administered a 240-mg dose of acetaminophen. A piggy-back infusion of 475 mg of cefuroxime IV was administered. I then proceeded to give her the prescribed dose of 190-mg azithromycin for her current infection. In the meantime, I noticed that her oxygen saturation was below 94 % and she wasn’t due for her albuterol inhaler for 2 more hours; therefore, I contacted the provider and was able to get more orders for her oxygen therapy. There was a stat order of 2.5 mg albuterol in the nebulizer, which I gave right away. Upon completion of this treatment, I put her back on the nasal cannula at 4 L/ minute per doctor order. 4. Document the patient teaching that you would provide for Sabina Vasquez and her family before discharge. Before discharge, I would provide Sabina and her family with specific teaching in regards to her current illness. I would advise Sabina to stay away from her allergy triggers as much as possible in order to prevent an asthmatic episode. In addition, Sabina and her parents should understand the asthma action plan. Lastly, I would tell both Sabina and her family that it is very important for her to complete her antibiotic treatment even if she starts to feel better. [Show More]

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