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GCS 15

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Sp O2 96% on RA

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Resources
Pt's maternal grandparents provide childcare for half-brother

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Medications
(1) fluticasone 50mcg/puff inhaler 2 puffs inhaled BID
(2) prednisolone sodium phosphate 10mg PO daily
(3) salbutamol 100mcg/puff inhaler 1 puff inhaled QID

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Data
Acute bronchitis
4 years old
21 kg

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Strengths
(1) Able to use faces scale
(2) Pt very talkative and verbally engages in assessment
(3) Pt eager to interact with healthcare staff

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Family
Pt's father at bedside in AM, ++ helpful and primary caregiver for pt.

Pt's mother visited in PM as well as step-father (parent's divorced). Pt asking for dad and Mom distressed.

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Pt reports "nothing hurts" and scores zero on faces scale

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Bowel sounds present, abdomen soft and rounded, last BM March 12th, up to void x 2, DAT

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Cap refill 1 second

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A x O x 3

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Fine crackles to rt base

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Mild WOB/SOB

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Temp 36.5 C

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RR 27 bpm

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HR 130bpm