Pediatric Case 2: Sabina Vasquez
Documentation Assignments
1. Document your initial focused assessment of Sabina Vasquez.
-She is breathing at 27 breaths per minute. There are a few audible wheezes. The chest is movin
...
Pediatric Case 2: Sabina Vasquez
Documentation Assignments
1. Document your initial focused assessment of Sabina Vasquez.
-She is breathing at 27 breaths per minute. There are a few audible wheezes. The chest is moving
equally. There is normal elasticity of the skin. She is sweating and her skin is warm.
-Lung sounds: There are reduced breath sounds at the right lung base. There are a few audible
wheezes
-Heart sounds: The heart rate and rhythm are regular without murmurs. The heart rate is fast
2. Identify and document key nursing diagnoses for Sabina Vasquez.
-Ineffective airway clearance R/T inflammation, increased secretions, mechanical obstruction, or
pain AEB the presence of secretions, productive cough, tachypnea, and increased work of breathing
-Gas exchange, impaired, R/T airway hyperinflation, atelectasis, ABE decreased oxygen saturation and alterations in arterial blood gases
-Fear R/T difficulty breathing, unfamiliar personnel, procedures, and environment (hospital),
AEB fussing and verbalization, or lack of cooperation
3. Referring to your feedback log, document the nursing care you provided and Sabina
Vasquez’s response.
The care I provided was to give the patient a stuffed animal and juice, this is the feedback log for
the patient.
Feedback Log
0:00 You arrived at the child.
0:00 You introduced yourself.
0:08 You washed your hands. To maintain patient safety it is important to wash your hands as
soon as you enter the room.
0:10 Child status - ECG: Sinus tachycardia. Heart rate: 145. Pulse: Present. Blood pressure:
120/80 mmHg. Respiration: 25. Conscious state: Appropriate. SpO2: 94%. Temp: 39.2 C
1:00 You identified the child. To maintain patient safety it is important that you quickly identify
the child.
1:09 You identified the relatives. This is important, as the patient is below 18 years of age.
1:10 Child status - ECG: Sinus tachycardia. Heart rate: 145. Pulse: Present. Blood pressure:
122/82 mmHg. Respiration: 26. Conscious state: Appropriate. SpO2: 93%. Temp: 39.2 C
1:21 You asked the parent: Does she have any known allergies? The parent replied: 'No. I
don't think so.'
1:44 You assessed the pain level using the FACES scale. The child answered 1 on the FACES
pain scale with a range of 0 to 5.
1:58 You asked the child if she had any pain. (Out of breath) She replied: 'Yes, I have
chest pain...'
2:07 You asked the child if anything made the pain better. (Out of breath) She replied: 'No,
not really.'
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