Surgical Case 4: Vernon Watkins
Documentation Assignments
1. Document Vernon Watkins’ respiratory assessment that occurred in the case. Pt. breathing
with equal chest rise and fall, lung sounds clear and equal bilateral. Pt RR 24 Pt is speaking
in full sentences however, Pt appears anxious with increased work of breathing. SP02 read
90% on room air. Pt states that it is painful to breath Pt rates pain at 3 out of 10 on the pain
scale.
2. Document the actions during the acute respiratory distress episode. Upon completing Pt
respiratory assessment Pt was assisted to the sitting position to better Pt breathing. 02 was
started 15lpm via non rebreather mask, and the provider was advised of the change in the
patient’s condition. The provider ordered a 12 lead EKG, chest Xray, Spiral CT of Pt chest,
ABG, venous blood sample. 6400 units of heparin were given IV bolus and a maintenance
drip of heparin was started in D5W rate 1440 units per hour.
3. Document the changes in Vernon Watkins’ vital signs throughout the scenario. Pt. initial
SP02 read 90% on room air upon initiating 02 therapy pt SP02 rose to 94% and Pt condition
improved. Pt seems more at ease with decreased anxiety noted. Pt breathing rate and
quality remained unchanged after treatment RR 24 with equal chest rise and fall. Pt heart
rhythm and rate remained sinus tach rate 102. Pt is still complaining of pain when breathing
and leg pain.
4. Identify and document key nursing diagnoses for Vernon Watkins. Impaired gas exchange
related to ventilation-perfusion imbalance as evidenced by dyspnea, restlessness and
apprehension
5. Referring to your feedback log, document the nursing care you provided. Upon speaking to
Pt a general impression of the patient was obtained. The patient was complaining of
difficulty in breathing while I washed my hands and obtained consent to treat. Pt was
positioned upright to facilitate breathing and an SP02 reading was obtained with 3 lead ECG
monitoring attached. SP02 read 90% on room air and a sinus tach rhythm on monitor was
noted rate 106 Pt RR was noted to be 24 with equal chest rise and fall lung sounds clear and
equal bilateral. 02 was administered per Dr standing orders at 15lpm via non rebreather
mask. The provider was notified of the Pt difficulty in breathing. The provider ordered a 12
lead ECG, spiral CT of the chest, a chest Xray, venous blood sample, ABG, Heparin 6400 units
loading bolus and 1440 units/hour in D5W maintenance drip. Pt vitals and pain were
monitored continuously while obtaining further Pt Hx. Pt has medical Hx of HTN and
smoking a half pack per day X50 years. Pt states that pain began suddenly in his chest and
rates the pain 3 out of 10 Pt also states that his leg hurts. Head to toe Pt assessment reveals
that Pt leg appears to be swollen and is painful. © Wolters Kluwer Health | Lippincott
Williams & Wilkins
Documentation Assignments
1. Document Vernon Watkins’ respiratory assessment that occurred in the case. Pt. breathing
with equal chest rise and fall, lung sounds clear and equal bilateral. Pt RR 24 Pt is speaking
in full sentences however, Pt appears anxious with increased work of breathing. SP02 read
90% on room air. Pt states that it is painful to breath Pt rates pain at 3 out of 10 on the pain
scale.
2. Document the actions during the acute respiratory distress episode. Upon completing Pt
respiratory assessment Pt was assisted to the sitting position to better Pt breathing. 02 was
started 15lpm via non rebreather mask, and the provider was advised of the change in the
patient’s condition. The provider ordered a 12 lead EKG, chest Xray, Spiral CT of Pt chest,
ABG, venous blood sample. 6400 units of heparin were given IV bolus and a maintenance
drip of heparin was started in D5W rate 1440 units per hour.
3. Document the changes in Vernon Watkins’ vital signs throughout the scenario. Pt. initial
SP02 read 90% on room air upon initiating 02 therapy pt SP02 rose to 94% and Pt condition
improved. Pt seems more at ease with decreased anxiety noted. Pt breathing rate and
quality remained unchanged after treatment RR 24 with equal chest rise and fall. Pt heart
rhythm and rate remained sinus tach rate 102. Pt is still complaining of pain when breathing
and leg pain.
4. Identify and document key nursing diagnoses for Vernon Watkins. Impaired gas exchange
related to ventilation-perfusion imbalance as evidenced by dyspnea, restlessness and
apprehension
5. Referring to your feedback log, document the nursing care you provided. Upon speaking to
Pt a general impression of the patient was obtained. The patient was complaining of
difficulty in breathing while I washed my hands and obtained consent to treat. Pt was
positioned upright to facilitate breathing and an SP02 reading was obtained with 3 lead ECG
monitoring attached. SP02 read 90% on room air and a sinus tach rhythm on monitor was
noted rate 106 Pt RR was noted to be 24 with equal chest rise and fall lung sounds clear and
equal bilateral. 02 was administered per Dr standing orders at 15lpm via non rebreather
mask. The provider was notified of the Pt difficulty in breathing. The provider ordered a 12
lead ECG, spiral CT of the chest, a chest Xray, venous blood sample, ABG, Heparin 6400 units
loading bolus and 1440 units/hour in D5W maintenance drip. Pt vitals and pain were
monitored continuously while obtaining further Pt Hx. Pt has medical Hx of HTN and
smoking a half pack per day X50 years. Pt states that pain began suddenly in his chest and
rates the pain 3 out of 10 Pt also states that his leg hurts. Head to toe Pt assessment reveals
that Pt leg appears to be swollen and is painful. © Wolters Kluwer Health | Lippincott
Williams & Wilkins
