Exam (elaborations) NURS MISC

1. Document your findings related to the focused assessments of Ms. Waterfall’s signs and symptoms of respiratory and/or cardiac distress. Include her responses to your assessment. L.W. was anxious upon me entering the room. Upon assessing her vitals, she was showing slight s/s of respiratory and cardiac distress. Her RR was elevated 24 breaths/min and she reported, “I feel like I can’t breathe.” Her lung sounds were clear and equal bilaterally. I took her radial pulse and it was strong and rapid at 110 bpm. Pt denied any chest pain, but reported, “It feels like my heart is racing.” Upon auscultation, heart sounds were regular with no murmurs. 2. Document your findings related to the focused assessment of Ms. Waterfall’s signs and symptoms of acute anxiety. Include her responses to your assessment. Acute anxiety s/s were evidence as soon as I walked into the room and introduced myself to L.W. and her cousin. L.W. said to her cousin, “Alice! Don’t leave me! Nuse, she said she wanted some coffee.” I reassured her that I would stay with her until her cousin returned. L.W. showed other signs of anxiety such as restless. During my assessment, she was unable to sit still. She had difficulty concentrating and was very scared. She repeatedly said she was very nervous. Her morning has only added to her anxiety about the sx. She could not find her medicine bundle, she broke a glass and she could not get in touch with her father. She claimed, “My life is falling apart!” I supported her through appropriate therapeutic communication. She’s receiving pressure from family to forgo sx and meet with tribal healers back at home, but is afraid to let down the surgical team who has worked hard to prepare her. I educated her on her rights and options, relieving the pressure on her. The surgeon will further assess her anxiety and make a decision with her regarding sx. 3. Referring to your feedback log, document all nursing care provided and Ms. Waterfall’s response to this care. ........................CONTINUED..............................