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Shadow Health Asthma Exacerbation Gabriel Martinez Documentation
PTCntrdCare:Chldbearing family (NURS 438)
Shepherd University
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11/4/22, 4:49 PM | Shadow Health® │ Digital Clinical Experiences™ from Elsevier
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Focused Exam: Asthma Exacerbation Results | Turned In
Patient Centered Care Child and Families - Fall 2022, NURS 430
Return to Assignment (/assignments/659600/)
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Documentation / Electronic Health Record
ED Nursing Note
Student Documentation Model Documentation
Chief Complaint
Asthma exacerbation, hard to breath, tightness in chest
Gabriel Martinez, age 8, came in to the ED with a moderate ast exacerbation, initially scoring a 9 on the PAS score. His exacer started 4 hours prior after he played kickball at his after-school program. His mother could not find his rescue inhaler, and whe peak flow meter readings were at 55-60% of his normal range, brought him to the ED. Gabriel was given albuterol treatment v nebulizer and an oral steroid. His most recent PAS score is a 5
History of Present Illness
-Pt. reports an asthma attack after playing kickball -Pt. was exhibiting wheezing and coughing -Mother reports peak flow meter readings at home of 55%, 59%, and 60% -Mother reporst that the rescue inhaler normally helps, however it was lost and the maintenance inhaler did not seem to do much
Gabriel Martinez is an 8-year-old boy who came to the ED experiencing a moderate asthma exacerbation. His initial score the PAS was a 9. His most recent PAS score is a 5. His exacer started 4 hours prior, after he was playing kickball at his after-s program. Gabriel was also exposed to secondhand smoke, wh known trigger for his asthma.
When Gabriel’s mom, Yvonne, picked him up from his program noticed he was coughing and having trouble breathing. His asth exacerbation worsened over the course of 4 hours, and Ms. Ma was unable to find Gabriel’s rescue inhaler. Gabriel said that he away his rescue inhaler a few weeks ago because he disliked t side effects. Gabriel’s peak flow meter readings at home were 5 59% and 60% of his normal. His mom tried administering an ex dose of his daily maintenance inhaler, but it was ineffective.
Gabriel ranks his current pain at a 4, and said he is experiencin soreness in his chest and neck. His cough is less frequent than was, and his wheezing is improved (only wheezing on expiratio
Your Results Lab Pass (/assignment_attempts/13286927/lab_pass.
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Care Plan
Student Survey
Flowsheets PreFlowsheets Documentation Preintervention PAS Score PAS Score
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Student Documentation Model Documentation
Allergies
-Tree pollen, pet dander, and dust trigger Gabriel's asthma, they make him short of breath or easier to get an asthma attack -otherwise no allergies
Patient has environmental allergies to pet dander, dust, and po No allergies to latex, medication, or food.
Home Medications
-maintainence inhaler - Fluticasone propionate, two times daily, two puffs at a time -rescue inhaler- two puffs, however it is "lost" -antihistamine
Albuterol MDI 90 mcg 1-2 puffs every 2-4 hours during breathin stress (Missing, needs refills) Flovent HFA (fluticasone propionate) MDI 44 mcg 2 puffs twice Occasional antihistamine if experiencing allergy symptoms Occasional Rx cream treatment for eczema
Past Medical History
-past hospitalization last year due to asthma -pt. is not exposed to second hand smoke -pt. has eczema
Mild persistent asthma step 2 since age 5 No previous surgeries
Social History
-Parent reports that too much exercise could trigger an asthma attack -pt. reports that exercising makes his asthma worse -pt. and mother live in an apartment -pt. is in third grade and goes to school -pt. goes to afterschool clubs and sometimes spends the night with his grandparents
Gabriel is in 3rd grade. He lives with his mom, Yvonne, in an apartment. Yvonne works at a law firm. He attends after-schoo programs during the school year, and has expressed an interes being more active or playing more sports. He enjoys playing vid games and spending time with his grandparents. Yvonne was concerned that he couldn’t do sports because of his asthma, bu provided some education around activities that are good for ch with asthma. Gabriel denies alcohol or tobacco use.
Review of Systems
-Pt. reports heart beating really fast -Pt. reports occasional rashes on elbows or hands -pt. reports feeling "mad" about having asthma
CARDIOVASCULAR: Heart is racing, possible albuterol side ef INTEGUMENTARY: No skin issues, but occasionally experienc eczema MENTAL HEALTH: Reports some frustration with asthma diagn
Family Medical History
-maternal grandfather has heart disease -maternal uncle has diabetes
No family history of asthma or other respiratory illness.
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Shadow Health Asthma Exacerbation Gabriel Martinez Documentation
Course: PTCntrdCare:Chldbearing family (NURS 438)
University: Shepherd University
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