Mona Hernandez Documentation Assignments

1. Document your focused assessment of Mona Hernandez.  Patient is a 72 year old female admitted in for pneumonia with no allergies. She is alert and orientated, but appears tired. She is experiencing shortness of breath and sharp pain when she coughs. Patient reported pain a 6/10. Her temperature was elevated, respirations were 24/min, blood pressure 112/72 and pulse was 104/min. Patient’s bed was raised into high-fowlers position. Oxygen was administered through a face mask 3L/min and O2 level increased to 95. 2. Document your assessment findings and any nursing interventions related to Mona Hernandez’s oxygenation after ambulation.  Oxygen was sitting at 88% so I raised the bed into high-fowlers position and administered oxygen via face mask at 3L/min. Patient was educated on oxygen therapy. I educated the patient on the use of a incentive spirometer. I had her cough into a basin, and then use the spirometer. 3. Document your education to Mona Hernandez regarding the purpose of, and how to use, the incentive spirometer.  Using the incentive spirometer encourages the patient to maximize lung inflation, it’s shows deep breathing and helps to support clearing secretions. In order to use the incentie spirometer, the patient inhales deeply and exhale normally. 4. Referring to your feedback log, document the nursing care you provided to Mona Hernandez and her response.