vSim Medical Scenario 3 Vincent Brody COPD and Spontaneous Pneumothorax Documentation.,WELL EXPLAINED

Documentation Assignments 1. Document your focused respiratory assessment for Vincent Brody. Focused respiratory assessment includes respiratory rate, chest movement and oxygen saturation to prevent further decline in oxygenation. Initial assessment: • Respiratory rate: 21 breaths per minute • SpO2: 93% with few audible wheezes and chest rise and fall bilaterally • Client stated that “this cough is killing me” When client complained of chest pain: • Client developed a left sided pneumothorax • Reduced breath sounds on the left lung and normal breath sounds on the right side • SpO2 started to decline After administration of Morphine, we should watch out for respiratory depression. 2. Identify and document key nursing diagnoses for Vincent Brody. • Acute Pain • Ineffective Breathing Pattern • Ineffective Peripheral Perfusion • Anxiety • Impaired Gas Exchange • Knowledge Deficient • Risk for Infection 3. Document pain management interventions and Vincent Brody’s response to therapy. Vincent complained about chest pain and 2 mg Morphine IV was administered per provider’s orders. Patient tolerated the medications well, and there was no sign of any respiratory distress. 4. Document key assessments you would monitor for a chest tube (insertion site, dressing, suction level, drainage, fluctuation, air leak). • Insertion site: monitor for any signs and symptoms of infection • Dressing: an occlusive sterile dressing is maintained on the insertion site • Suction level: mark the chest tube suction level at 1 to 4-hour intervals • Drainage: notify provider if drainage is more than 100 mL/hr or if it becomes bright red and increases suddenly • Fluctuation: check for kinks in the tubing and check lung sounds