NURS 3430 Vsim 2 Jennifer Hoffman Documentation

1. Document your initial focused respiratory assessment of Jennifer Hoffman. Upon entering Mrs. Hoffman’s room I washed my hands and identified myself. She was in obvious respiratory distress so I decided to go ahead and check her vitals. Her pulse was strong and tachycardia. I assessed her respiratory effort and rate, It was a rate of 30 with increased effort. I then proceeded to auscultate her lungs where I heard audible wheezing. After placing the pulse ox I saw that her oxygen saturation was 74% and dropping. This is when I decided to go ahead and intervene with supplying oxygen. 2. Identify and document key nursing diagnoses for Jennifer Hoffman. -Ineffective airway clearance R/T tracheobronchial narrowing AEB audible wheezing and increased respiratory effort -Ineffective breathing pattern R/T bronchospasms and anxiety AEB increased respiratory effort and rate and decreased oxygen saturation -Anxiety R/T inability to breathe effectively AEB hyperventilation and panicked expression 3. Referring to your feedback log, document the nursing care you provided. 1. Washed my hands and Identified the patient 2. Asked about allergies- “Hay fever” was the response 3. Asked the patient how she felt, she responded “not good” 4. Attached the pulse ox (74%) 5. Assessed respirations/ effort (RR:30, Increased effort) 6. Checked the rest of the vitals: HR: 114, BP: 129/75, Temp: 99; radial pulse strong 105BPM 7. Applied nasal cannula 4L/min - oxygen was not sufficient to reach and maintain 92% saturation. 8. Applied non-rebreather mask 10L/min- Oxygen was sufficient to reach and maintain over 92% O2 saturation , I humidified the air. 9. Attached 3-lead ECG 10. Assessed IV site and flushed 11. Administered the ordered medications: Albuterol 5 mg, Ipratropium 500mcg, Methylprednisolone 100mg . 12. Reassessed breathing pattern and rate, and auscultated the lungs again 13. I asked the patient if she felt better and she responded “yes, much better, thanks ..................................................CONTINUED..............................