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Pediatric Case 4: Sabina Vasquez (Complex)
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1A: Sabina Vasquez (Core) Documentation Assignments 1. Document your initial focused assessment of Sabina Vasquez. 2. Identify and document key nursing …
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Document the patient teaching that you would prove for Sabina Vasquez and her family before discharge. From vSim for Nursing | Pediatric.
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Vsim Sabina Vasquez Dialogue | PDF | Heart | Pneumonia
Sabina Vasquez. Age: 5 years. Diagnosis: Asthma and pneumonia. Score 0 100. m er as 0. co 0. eH w o. Feedback Log rs e ou urc o aC s vi y re ed d ar stu …
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Pediatric Case 4: Sabina Vasquez (Complex) Documentation Assignments
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Long Island University VSim Core and Complex Documentation Questions
This is one assignment contain 2 scenarios (1 core, and 1 Complex). Please answer the questions for each scenario that highlighted in blue (1A, 1B, 2A, 2B). Those in yellow are examples that are found online. Please do not copy them, just rephrase them by using the scenarios and pick some info from the examples to make the work easier. (1 page for 1A, 1B, 2A, 2B to make it a total of 4 pages and reference page, you can use any other document for citation. Thank you. 1) Core Scenario Sabina Vasquez is a 5-year-old Hispanic girl being seen in the pediatric clinic today for breathing problems. She has a history of asthma but is otherwise healthy. She was seen in the clinic once before at age 4 for a health supervision visit (well-child checkup). Her asthma was well controlled, and medications were renewed. Her immunizations are up to date. The family moved here from Mexico two years ago. 1A: Sabina Vasquez (Core) Documentation Assignments 1. Document your initial focused assessment of Sabina Vasquez. 2. Identify and document key nursing diagnoses for Sabina Vasquez. 3. Referring to your feedback log, document the nursing care you provided and Sabina Vasquez’s response. 4. Document the patient teaching that you would provide for Sabina Vasquez and her family before disc Please follow the Sample/Example “Core” below Sabina Vasquez (Core) Documentation Assignments 1. Document your initial focused assessment of Sabina Vasquez. I assessed Sabina’s breathing patterns and listened to her lungs, found that she was wheezing and having difficulty breathing. I asked her what she was doing at the time and spoke to the mom regarding any possible allergens that could have set off the attack. 2. Identify and document key nursing diagnoses for Sabina Vasquez. Ineffective breathing pattern R/T asthma AEB difficulty breathing. Ineffective airway clearance R/T asthma AEB audible wheezing. 3. Referring to your feedback log, document the nursing care you provided and Sabina Vasquez’s response. I introduced myself to the patient, washed my hands then identified her and the adult in the room. I asked Sabina why she was at the hospital, she said she couldn’t breathe. I asked her what she was doing when it started and if she was in any pain. She denied any pain and said she was outside playing. I checked with her mom about any possible allergies or recent allergen exposure and she said there were none. Her mom said she has been coughing recently. I listened to the patient’s lungs and heard wheezing. I checked her vitals and offered her a toy which she was happy to have. I then phoned the doctor for orders. The dr. ordered a nebulizer treatment and peak flow testing. 4. Document the patient teaching that you would provide for Sabina Vasquez and her family before discharge. Sabina should be taking her medication exactly how it is prescribed, even if she feels like it is under control. She and her family should know now to monitor her asthma and use a peak flow meter to help keep track. She should also always carry her rescue inhaler. Her family should be sure to avoid having Sabina be in contact with any triggers that may aggravate her asthma such as dust, pets and smoking. 1 B: Sabina Vasquez (Core) Guided Reflection Questions How did the simulated experience of Sabina Vasquez’s case make you feel? Describe the actions you felt went well in this scenario. Scenario Analysis Questions* EBP What priority problem did you identify for Sabina Vasquez? EBP What complications might Sabina Vasquez face if her symptoms are not recognized and treated in a timely manner? PCC Describe the barriers that Sabina Vasquez and her family may encounter that would hinder active participation in Sabina’s care. PCC What should be done to overcome the language barrier between the health care team and Sabina’s mother? PCC Describe age-appropriate strategies to empower Sabina Vasquez and her mother in all aspects of the health care process. PCC What is your attitude toward Sabina Vasquez’s cultural background? How might your attitude affect the care you provide to Sabina and her family? PCC What teaching needs to be given to Sabina Vasquez and her mother on the management of her asthma? PCC Identify the possible triggers of Sabina Vasquez’s asthma exacerbation and assist the family in developing a plan of action to mitigate these triggers. S/QI Reflect on ways to improve safety and quality of care based on your experience with Sabina Vasquez’s case. T&C What role does Sabina Vasquez’s mother have as a member of her health care team? (Explain your answer.) T&C/I What key elements would you include in the handoff report for this patient? Consider the situation-background-assessment-recommendation (SBAR) format. I Describe the importance of using an approved, trained interpreter rather than a family member or ancillary staff member for data collection and teaching in Sabina Vasquez’s case. Concluding Questions Reflecting on Sabina Vasquez’s case, were there any actions you would do differently? If so, what were these actions, and why would you do them differently? Describe how you would apply the knowledge and skills you obtained in Sabina Vasquez’s case to an actual patient care situation. Please follow the Sample/Example “Core Reflection” below Sabina Vasquez Guided Reflection Questions How did the simulated experience of Sabina Vasquez’s case make you feel? I actually felt a slight amount of what I realized was confidence as I worked through this scenario. It felt great! Describe the actions you felt went well in this scenario. As I ran through the scenario for the first time, I felt pretty confident as I handed the patient’s care off to the next nurse. When I received my score (92%) I realized that I had completely forgotten to go through the education for both the patient and the family. I made sure to re-do the scenario, and was able to achieve a 100% score on the simulation. EBP What priority problem did you identify for Sabina Vasquez? It appeared that the patient was experiencing breathing trouble. She was having an asthma attack. EBP What complications might Sabina Vasquez face if her symptoms are not recognized and treated in a timely manner? Possible complications can range from decreased oxygen saturation, all the way to respiratory distress, respiratory arrest and even death. PCC Describe the barriers that Sabina Vasquez and her family may encounter that would hinder active participation in Sabina’s care. I realized almost immediately that there might be a language barrier. It sounded like mom spoke Spanish as her primary language. PCC What should be done to overcome the language barrier between the health care team and Sabina’s mother? Anytime there is a language issue, it is imperative to acquire a professional medical translator. PCC Describe age-appropriate strategies to empower Sabina Vasquez and her mother in all aspects of the health care process. Teaching is the key to empowering the patient, and also her family. Age appropriate strategies might include using the inhaler prior to playing soccer. The mother needs to keep her daughter current on all of her immunizations to try and prevent illness and infections. If the family has pets, they should strongly consider re-homing the pets in an effort to reduce the amount of allergens and/or pet dander in the house. If anyone living in the house is a smoker, they should be encouraged to start a smoking cessation program, or at least make sure to never smoke in or around the house. PCC What is your attitude toward Sabina Vasquez’s cultural background? How might your attitude affect the care you provide to Sabina and her family? I love the Hispanic community. I have a number of very dear friends that are Spanish and come from a Hispanic heritage and culture. I have a very positive attitude when it comes to providing care for patients of Hispanic origin and background. Generally speaking, they are a wonderfully kind people. PCC What teaching needs to be given to Sabina Vasquez and her mother on the management of her asthma? The specific teaching that should be given to this patient and her mother might include using the inhaler prior to playing soccer, staying up to date on all vaccinations, removing pets and carpet from the house as much as is appropriate, reducing or removing the patient’s exposure to smoke of any kind, but particularly tobacco smoke. PCC Identify the possible triggers of Sabina Vasquez’s asthma exacerbation and assist the family in developing a plan of action to mitigate these triggers. When interviewing the mother of the patient, she mentioned that she thought the patient had an allergy to pollen. This is an important piece of information when helping the family construct a plan of action to help this patient avoid asthma triggers. S/QI Reflect on ways to improve safety and quality of care based on your experience with Sabina Vasquez’s case. Important teaching points should include striving to increase safety in and around the home. These suggestions might include reducing carpet as much as possible in the house. Hard floors need to be mopped regularly to help avoid buildup of dust and allergens. The family needs to try and reduce or remove the number of pets in the house. Smoking in the house needs to immediately reduced, or hopefully removed. T&C What role does Sabina Vasquez’s mother have as a member of her health care team? (Explain your answer.) She is probably the coordinator of care. Since the patient is only five years old, her mother is going to be the primary care giver, and also her biggest advocate. T&C/I What key elements would you include in the handoff report for this patient? Consider the situation-background-assessment-recommendation (SBAR) format. I would make sure to give the information that would help the nurse coming on shift to provide the best care for the patient. This would include a detailed history of the patient’s current situation, along with her previous asthma history. I would make sure to lay out all the interventions performed up to this point, and finally go over the plan and my take on how things have gone so far, and if I have any suggestions. I Describe the importance of using an approved, trained interpreter rather than a family member or ancillary staff member for data collection and teaching in Sabina Vasquez’s case. Family members or untrained staff members are not specialized in medical translation, and may not be able to explain situations accurately. They may not be able to translate the words the doctor is using, simply because they don’t know the words being used. All of these things might add up to a lack of information, which could negatively impact the care the patient ultimately, receives. Concluding Questions Reflecting on Sabina Vasquez’s case, were there any actions you would do differently? If so, what were these actions, and why would you do them differently? Overall, I felt like this scenario went very well. I redid the simulation twice, so I could correct the mistakes I made the first time. I was very happy with my score the second time running through the simulation. Describe how you would apply the knowledge and skills you obtained in Sabina Vasquez’s case to an actual patient care situation. I will take the knowledge I gained during this simulation and tuck a few things away. I will make sure to always use an approved translator if there are any language barriers. I will also make sure to utilize the education I have at my disposal to teach not only my patient, but to teach the family. This will help to empower them and put the patient in the best place to receive the very best care possible. 2) Complex Scenario Sabina Vasquez is a 5-year-old Hispanic girl admitted today from the emergency room with a diagnosis of pneumonia. She has a history of asthma and has had several episodes requiring use of an albuterol inhaler at home. Sabina has had an upper airway infection for the past few days. Earlier today she developed a fever of 39°C (102.2°F), so her mother brought her to the emergency room. She was placed on oxygen via nasal cannula at 2 L/min. She received a 380-mL bolus of normal saline and an albuterol nebulizer treatment at 5:00 PM. This improved her oxygen saturation to 94%. The chest x-ray revealed right lower lobe pneumonia with effusion. An intravenous infusion of D5 ½NS is infusing at 61 mL/hr. Sabina just got settled in bed, and her mother is at the bedside. 2 A: Sabina Vasquez (Complex) Documentation Assignments 1. Document your initial focused assessment of Sabina Vasquez. 2. Identify and document key nursing diagnoses for Sabina Vasquez. 3. Referring to your feedback log, document the nursing care you provided and Sabina Vasquez’s response. 4. Document the patient teaching that you would provide for Sabina Vasquez and her family before discharge. Please follow the Sample/Example “complex Documentation” below Sabina Vasquez Documentation Assignments 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 pulse 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 r/t excess mucous production and carbon dioxide retention -Risk for activity intolerance r/t respiratory condition as evidenced by pneumonia -Ineffective airway clearance r/t infection as evidenced by pneumonia -Ineffective breathing pattern r/t pain as evidenced by chest pain -Impaired comfort r/t illness-related symptoms as evidenced by dyspnea -Risk for electrolyte imbalance r/t 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 teachings 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. 2 B: “Reflection complex” Sabina Vasquez (Complex) Guided Reflection Questions How did the simulated experience of Sabina Vasquez’s case make you feel? Describe the actions you felt went well in this scenario. EBP List in order of priority your initial nursing actions for Sabina Vasquez based on physical findings and family interaction. EBP What complications might Sabina Vasquez face if her symptoms are not recognized and if care is not initiated in a timely manner? PCC What actions should be taken to ensure the delivery of appropriate information to Sabina Vasquez’s mother? PCC Recognizing the acuity of the situation, how would you include Sabina Vasquez and her mother in the decision-making process? S/QI Reflect on ways to improve safety and quality of care based on your experience with Sabina Vasquez’s case. T&C/I What key elements would you include in the handoff report for this patient? Consider the situation-background-assessment-recommendation (SBAR) format. QI As you begin to think about discharge planning for Sabina Vasquez and her family, what teaching needs to be provided? Concluding Questions Reflecting on Sabina Vasquez’s case, were there any actions you would do differently? If so, what were these actions, and why would you do them differently? Describe how you would apply the knowledge and skills obtained in Sabina Vasquez’s case to an actual patient care situation. Sample Reflection Questions Sabina Vasquez (Complex) Guided Reflection Questions Opening Questions How did the simulated experience of Sabina Vasquez’s case make you feel? As any other VSIM, Sabina made me feel uncomfortable. Sabina adds another level of complexity, where a child comes in with respiratory disease, already has a condition that can amplify possible problems. I think Sabina is an excellent introduction to a real-life patient scenario. They most likely have multiple issues wrong with them and the nurse has to think of how disease processes will interact and how will that apply to the patient. Sabina had two inflammatory disease, pneumonia as an acute infection, and asthma as chronic inflammatory condition. Describe the actions you felt went well in this scenario. I feel like I followed through the orders correctly and efficiently. I recognized that Sabina was in distress, and she needed another dose of albuterol. I contacted the doctor to deal with the problem at hand, and I had no problem picking what medication was the priority. Albuterol took the first place, to alleviate girls bronhospasm, then I proceeded with medication to treat the fever and antibiotics. Even though this is not available in this simulation, one of my first thoughts was a need for an interpreter. I knew that we should provide them with appropriate language services in case they weren’t comfortable with english. EBP List in order of priority your initial nursing actions for Sabina Vasquez based on physical findings and family interaction. 1) Elevate the head of the bed to provide a position of comfort and to relieve respiratory distress, 2) increase oxygen to 4 L via a nasal cannula, 3) administer albuterol, 4) notify the primary care provider. EBP What complications might Sabina Vasquez face if her symptoms are not recognized and if care is not initiated in a timely manner? Acute pneumonia may progress to severe hypoxia leading to respiratory failure and possible death. PCC What actions should be taken to ensure the delivery of appropriate information to Sabina Vasquez’s mother? Because sabina’s mother has limited English, a trained, approved interpreter is legally required to assist with communication. PCC Recognizing the acuity of the situation, how would you include Sabina Vasquez and her mother in the decision-making process? Discussion should include the following: the importance of recognizing communication barriers; the use of eye contact, simple statements, and hand gestures, the use of therapeutic touch by both the nurse and mother, and the encouragement of the mother’s active support and engagement in providing care for Sabina as appropriate. S/QI Reflect on ways to improve safety and quality of care based on your experience with Sabina Vasquez’s case. Possible areas for improvement include medication administration and drug calculations (right of medication administration to include oxygen), patient/family teaching (using an interpreter, discussing medication administration to include timing, providing information on side effects, educating on triggers, recognizing signs and symptoms, and providing written instruction in Spanish), and equipment use (demonstration of appropriate use of medication delivery devices to include nebulizer and intravenous (IV) piggyback and appropriate documentation). T&C/I Whatkeyelementswouldyouincludeinthehandoffreportforthispatient? Consider the situation-background-assessment-recommendation (SBAR) format. S: Sabina Vasquez, 5 year old, Hispanic girl came in with her mother to the ER with pneumonia. She has a history asthma and has had several episodes requiring use of an albuterol inhaler at home. B: Sabina’s mother reports her daughter had an upper airway infection for a couple of days, and today she developed 39 C fever; therefore, she brought her in. She is now on 4L/min humidified nasal cannula. She got a 380 mL bolus of NS and albuterol at 1700. When I saw her at 1900, she had: difficulty breathing, unproductive cough, and some wheezing. Along with reduce breath sounds at the right lung base, SpO2 92% respiration rate 29/min, and temperature 39.1C; We got an extra dose of 2.5 mg albuterol nebulizer to ease the bronchospasm from the provider; 240 mL of acetaminophen for the fever; piggyback infusion of 475 mg of cefuroxime IV for pneumonia; also a 190-mg oral dose of azithromycin for pneumonia. An intravenous injection of D5 1/2NS is infusing at 61mL/hr. A: I believe sabinas airway is hyperactive during illness due to increased inflammation caused by pneumonia. R: Sabina’s airway should be monitored carefully, and the mother should be encouraged to call for help if she sees and hears any complaint of dyspnea so that we can manage asthma and pneumonia efficiently. Monitor for signs and symptoms of antibiotic hypersensitivity. There are two antibiotics ordered for treatment of pneumonia, that should be discussed and reinforced with Sabina’s mother, so that she will receive a full treatment after she is discharged home. QI As you begin to think about discharge planning for Sabina Vasquez and her family, what teaching needs to be provided? Students should incorporate the asthma action plan during patient and family teaching on signs and symptoms, asthma triggers, and the effect of the chronic illness on the family. Concluding Questions Reflecting on Sabina Vasquez’s case, were there any actions you would do differently? If so, what were these actions, and why would you do them differently? According to VSIM grading, there wasn’t much I should do differently, but in real life, I would add a lot more education for Sabina’s mother. After Sabina gets her albuterol and we monitor her for improvement I think it’s a good timing to begin talking about asthma action plan,and explain why is she having this difficulty breathing because of the pneumonia as well. This way we can lower Sabinas mother stress, therefore indirectly Sabina will fell more comfortable with mom that is less anxious. I believe that as a practicing nurse you should be talking to the patient in simple terms what are you doing to them. For example, in the VSIM, medication administration is quiet, and the nurse does not give any information about what she is giving to Sabina. This is again a goof time for teaching, and keeping the mother involved and informed. Describe how you would apply the knowledge and skills obtained in Sabina Vasquez’s case to an actual patient care situation. This scenario was great review of pneumonia and asthma. In my clinical rotation in the school district, I am now aware that the nurse should have an asthma action plan in case a child needs an inhaler. The review of the medication and inhalers will help me look for proper use of them in the nurse’s office to ensure adequate administration. Sabina’s case also made me think about the cultural aspect of nursing, that use of bilingual pamphlets can increase compliance with new medication. [*] The Scenario Analysis Questions are correlated to the Quality and Safety Education for Nurses (QSEN) competencies: Patient-Centered Care (PCC), Teamwork and Collaboration (T&C), Evidence-Based Practice (EBP), Quality Improvement (QI), Safety (S), and Informatics (I). Find more information at: http://qsen.org/
Sabina vasquez vsim documentation
I’m stuck on a Nursing question and need an explanation. Please answer the Documentation Assignments (file: DA) and Scenario Analysis Questions (file: GRQ) in the uploaded files, using the feedback log as a reference. Answers only need to be 2-5 sentences max. 😬 Correlating files are indicated by # and core or complex (ex: PediatricCase04_xx_Complex_) & (4_FeedbackLog)Pediatric Case 4: Sabina Vasquez (Complex) Documentation Assignments 1. Document your initial focused assessment of Sabina Vasquez. 2. Identify and document key nursing diagnoses for Sabina Vasquez. 3. Referring to your feedback log, document the nursing care you provided and Sabina Vasquez’s response. 4. Document the patient teaching that you would provide for Sabina Vasquez and her family before discharge. From vSim for Nursing | Pediatric. © Wolters Kluwer …
I’m stuck on a Nursing question and need an explanation.
Please answer the Documentation Assignments (file: DA) and Scenario Analysis Questions (file: GRQ) in the uploaded files, using the feedback log as a reference. Answers only need to be 2-5 sentences max. 😬
Correlating files are indicated by # and core or complex (ex: PediatricCase04_xx_Complex_) & (4_FeedbackLog)Pediatric Case 4: Sabina Vasquez (Complex) Documentation Assignments 1. Document your initial focused assessment of Sabina Vasquez. 2. Identify and document key nursing diagnoses for Sabina Vasquez. 3. Referring to your feedback log, document the nursing care you provided and Sabina Vasquez’s response. 4. Document the patient teaching that you would provide for Sabina Vasquez and her family before discharge. From vSim for Nursing | Pediatric. © Wolters Kluwer Health. Pediatric Case 4: Sabina Vasquez (Complex) Guided Reflection Questions Opening Questions How did the simulated experience of Sabina Vasquez’s case make you feel? Describe the actions you felt went well in this scenario. Scenario Analysis Questions* EBP List in order of priority your initial nursing actions for Sabina Vasquez based on physical findings and family interaction. EBP What complications might Sabina Vasquez face if her symptoms are not recognized and if care is not initiated in a timely manner? PCC What actions should be taken to ensure the delivery of appropriate information to Sabina Vasquez’s mother? PCC Recognizing the acuity of the situation, how would you include Sabina Vasquez and her mother in the decision-making process? S/QI Reflect on ways to improve safety and quality of care based on your experience with Sabina Vasquez’s case. T&C/I What key elements would you include in the handoff report for this patient? Consider the situation-background-assessment-recommendation (SBAR) format.
Pediatric Case 4: Sabina Vasquez (Complex) Documentation Assignments
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