Pediatric Case 5: Charlie Snow
Documentation Assignments
1. Document your initial focused assessment of Charlie Snow.
Charlie Snow 6y/o presenting an anaphylactic reaction, allergic to peanuts. Heart rate: 156.
Pulse: Present. Blood pressure: 109/72 mmHg. Respiration: 30. Conscious state: Appropriate.
SpO2: 91%. Temp: 37.2 C. He is breathing at 25 breaths per minute. He has retractions, a
prolonged expiration phase, and a lot of audible wheezing. There is increased respiratory
effort.
2. Identify and document key nursing diagnoses for Charlie Snow.
Ineffective airway clearance related to inflammation.
3. Referring to your feedback log, document the nursing care you provided and
Charlie Snow’s response.
- I washed my hands.
- identified the patient and the relatives in the room. Consent for treatment was given as the
relatives were not the parents.
- I asked about allergies and health problems.
- I assessed vital signs
- I attached ECG monitoring
- The physician was called and informed of the patient’s condition.
- 100% oxygen from a nonrebreathing mask at 10L/min (O2 saturation was not getting better
with nasal cannula)
- A bolus of 420 mL of normal saline IV, given over 30 minutes.
- administered 0.3 mg of epinephrine 1:10000 IV push.
- administered 25 mg of diphenhydramine IV push.
- administered 20 mg of ranitidine IV.
- administered 10 mg of methylprednisolone IV.
Documentation Assignments
1. Document your initial focused assessment of Charlie Snow.
Charlie Snow 6y/o presenting an anaphylactic reaction, allergic to peanuts. Heart rate: 156.
Pulse: Present. Blood pressure: 109/72 mmHg. Respiration: 30. Conscious state: Appropriate.
SpO2: 91%. Temp: 37.2 C. He is breathing at 25 breaths per minute. He has retractions, a
prolonged expiration phase, and a lot of audible wheezing. There is increased respiratory
effort.
2. Identify and document key nursing diagnoses for Charlie Snow.
Ineffective airway clearance related to inflammation.
3. Referring to your feedback log, document the nursing care you provided and
Charlie Snow’s response.
- I washed my hands.
- identified the patient and the relatives in the room. Consent for treatment was given as the
relatives were not the parents.
- I asked about allergies and health problems.
- I assessed vital signs
- I attached ECG monitoring
- The physician was called and informed of the patient’s condition.
- 100% oxygen from a nonrebreathing mask at 10L/min (O2 saturation was not getting better
with nasal cannula)
- A bolus of 420 mL of normal saline IV, given over 30 minutes.
- administered 0.3 mg of epinephrine 1:10000 IV push.
- administered 25 mg of diphenhydramine IV push.
- administered 20 mg of ranitidine IV.
- administered 10 mg of methylprednisolone IV.
