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Pediatric Case 3: Sabina Vasquez (Core) 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 related to excess mucous production and carbon dioxide retention, Risk for activity intolerance related to respiratory condition as evidenced by pneumonia, Ineffective airway clearance related to infection as evidence by pneumonia, Ineffective breathing pattern related to pain as evidenced by chest pain, Impaired comfort related to illness-related symptoms as evidenced by dyspnea, risk for electrolyte imbalance related to insufficient fluid volume.