Medical Case 2 Jennifer Hoffman- Guided Reflection Questions.

Medical Case 2: Jennifer Hoffman Documentation Assignments 1. Document your initial focused respiratory assessment of Jennifer Hoffman. The initial focused respiratory assessment findings were as followed; Sinus tachycardia, HR: 117 bpm, Pulse: represent strong 100 bpm and irregular, BP: 132/79 mmHg, RR: 25 breaths/min, Sp02: 79%, T: 99 F, Lung Sounds: audible wheezing in the chest w/ increased respiratory effort, Heart Sounds: normal sounds no m/g/r, Skin Turgor: normal turgor, skin is bluish w/ present diaphoresis and cool. 2. Identify and document key nursing diagnoses for Jennifer Hoffman. 1) Ineffective breathing pattern related to asthma, 2) Anxiety related to asthma 3. Referring to your feedback log, document the nursing care you provided. Head of the bed was elevated to increase ease of oxygenation. Patient had a respiratory assessment and vital signs were taken to create a baseline. Informed consent was signed to perform care for the patient. Patient was asked to rate pain on a scale of 0 - 10 as well having him explain his current symptoms. Patient was given an albuterol nebulizer treatment. After labs to test ABG’s were taken, patient began to complain of chest pain. HCP was called and per provider orders, chest x-ray was complete, I administered 2 mL of morphine, and assisted with the insertion of the chest tube. Patient was assessed before and after procedure.