Name of Student: Lyza Mae D.

Fernandez BSN 2-F

Inclusive date of exposure: January 16-18, 2023
Area of Exposure: Pedia Simulation (VSAC)
Clinical Instructor: Ms. Gelina Li, RN, MN

Problem List
Patient’s Age and Sex: 6 years old, Female
Medical Diagnosis of patient: Bronchial Asthma
CUES PROBLEMS PRIORITY PHYSIOLOGICAL BEHAVIORAL
ACTUAL POTENTIAL ACTUAL POTENTIAL
Subjective Data:
Dyspnea Ineffective Risk for Fear related to Disturbed sleep
“Mama indi ko ka breathing activity fear of an pattern related to
breathe” verbalized by Wheezing pattern related intolerance event as discomfort. 2°
the patient. to presence of related to evidenced by bronchial asthma.
Tachypnea shortness of decreased alertness. 2°
"Nurse lihog ko bi danay breath 2° oxygenation bronchial
sa akon bata kay grabi na Diaphoresis Dyspnea bronchial 2° bronchial asthma.
iya hapo, gina nebulize asthma. asthma.
siya namon sa balay pero Retractions
ga sige nga ga sige
gyapon iya hapo. Ano Increased
mahimo ko nurse para respiration
lang mahagan-haganan rate
ang pamatyag ya?"
verbalized by the mother.
Ineffective Risk for Knowledge Readiness for
airway aspiration Deficit related to enhanced
Objective Data: Wheezing clearance related to inability to follow knowledge as
related to impaired through care. 2° evidenced
Vital Signs: impaired swallowing 2° bronchial verbalization of
respiratory Bronchial asthma desire to optimize
● BP : 70/40 mmHg muscle asthma. wellness. 2°
(NORMAL: function as bronchial asthma
105/70mmHg)
 evidenced by
●SpO2: 93% on room air abnormal
(NORMAL: 95-100%) breath sounds
2°
Bronchial
● Temperature: 38.3°C asthma.
(NORMAL:
36.1 - 37°C)

● Heart Rate:
131bpm
(NORMAL: 70-110bpm)

●Respiration Rate:
32cpm (NORMAL:
20-30cpm)

2 seconds
capillary refill

Tachypnea Ineffective Impaired Fear related to Anxiety related to

breathing physical unfamiliar changes to
pattern related mobility related environment as environment and
to anxiety as to activity evidenced by routines. 2°
evidenced by intolerance. 2° identifies object Bronchial
increased Bronchial of fear. 2° asthma.
anteroposterior asthma. Bronchial
chest. 2° asthma.
Bronchial
asthma.