1. Document your initial focused assessment of Sabina Vasquez.
I started off with washing my hands, identified my patient and her mother, obtained consent, and
asked about her allergies then I asked the mother what sta
...
1. Document your initial focused assessment of Sabina Vasquez.
I started off with washing my hands, identified my patient and her mother, obtained consent, and
asked about her allergies then I asked the mother what started the problem, the mother replied
that a few hours ago when she was playing outside, she started to feel short of breath. Patient
vital signs: Heart rate: 129. Blood pressure: 118/80 mmHg. Respiration: 19. SpO2: 95%. Temp:
36.2 C. I listened to her lungs posteriorly; noted few audible wheezes. In real clinical situation, I
would auscultate the patient’s lungs both anteriorly and posteriorly. After assessing her pain level
using FLACES scale, I called the doctor and received new orders. Next I check her peak flow
level before and after administration of 2.5-mg dose of albuterol in a nebulizer as per the MAR.
Lastly, I provided patient education before handing off and completing the sim.
2. Identify and document key nursing diagnoses for Sabina Vasquez.
Some of the nursing diagnosis related to Sabina’s condition would be ineffective breathing
pattern, ineffective airway clearance, and activity intolerance.
3. Referring to your feedback log, document the nursing care you provided and Sabina Vasquez’s
response.
Some of the nursing interventions that I performed during the sim to alleviate patient’s
discomfort were;
- Assessed vital signs including O2 levels, and completed respiratory system assessment
- Contact the Doctor and received new orders
- Administered albuterol in a nebulizer as per the MAR order.
- Checked peak flow meter levels before and after administration of the nebulizer.
- Provided patient teaching for medication administration rationale and how to manage
asthma at home
4. Document the patient teaching that you would provide for Sabina Vasquez and her family before
discharge.
I would teach the patient and her mother;
- How to measure peak flow meter at home; before and after taking her inhaler and to
know her baseline.
- How to avoid allergens to prevent future asthma exacerbation
- To use inhaler prior to commencing any type of exercise or activity
- Remind Sabina’s mother to keep her daughter’s immunizations up to date
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