peps C2++

This is an example of the Documentation

Pediatric Case 4: Sabina Vasquez (Complex)

Documentation Assignments

1. Document your initial focused assessment of Sabina Vasquez.

My initial assessment was: Sabina’s airway, examining her respiration, apical pulse and blood pressure, temperature, pain assessment with FACES

T: 102 BP: 120/80

BR: 29 wheezing, reduced breath sound pain: 1 scale 0 to 5

HR: 147 SPO2: 96

2. Identify and document key nursing diagnoses for Sabina Vasquez.

Impaired gas exchange evidenced by excess mucous production

Ineffective airway clearance as evidenced by pneumonia

Impaired comfort illness related symptoms as evidenced by dyspnea.

3. Referring to your feedback log, document the nursing care you provided and Sabina Vasquez’s response.

Sabina a nursing care delivered in response to her pneumonia: I took temperature it was 102 and advised them to drink enough fluid; I administered 240 mg dose of acetaminophen for pain. A piggy-back infusion of 475 cefuroxime IV was administered. Next, I have given her the prescription of 190mg azithromycin for her infection. Then, as her oxygen was 92% and her stat order for albuterol due in two hours so I contacted her provider to deliver a stat order 2.5 mg albuterol. I gave the albuterol 2.5mg immediately. Finally, I put the 4mL nasal cannula.

4. Document the patient teaching that you would provide for Sabina Vasquez and her family before discharge.

I taught them:

· Stay away from her allergy triggers such as pollens, dusts, animal fur

USING A PEAK FLOW METER

• Slide the arrow down to “zero.”

• Stand up straight. • Take a deep breath and close the lips tightly around the mouthpiece. • Blow out hard and fast. • Note the number the arrow moves to. • Repeat three times and record the highest reading. • Keep a record of daily readings, being sure to measure peak flow at the same time each day.

Educate families and children on the appropriate use of nebulizers, metered-dose inhalers, spacers, dry-powder inhalers

Advised Sabina to complete her antibiotic treatment even if she feels better.

From vSim for Nursing | Pediatric. © Wolters Kluwer Health.