Documentation assignement Vernon Watkins PDF

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Surgical Case 4: Vernon Watkins Documentation Assignments 1. Document Vernon Watkins’ respiratory assessment that occurred in the case.  Patient breathing with equal chest rise and fall.  Lung sounds are clear and are equal bilaterally.  Patient respiratory rate 24.  Patient appear anxious with increase respiration  Spo2 reading 93 percent on room air.

2. Document the actions during the acute respiratory distress episode.  Upon completing patient respiratory assessment patient was assisted to sitting position to better breathing.  The provider ordered a 3 lead EKG and chest x ray  Spiral CT of the patient chest, ABG, venous blood sample. Heparin 80 units/kg IV bolus and a maintenance dose of heparin 25000 units in 250mL of dextrose 5% in water was given.  Patient’s vital signs were continuously assessed and the primary provider orders.

3. Document the changes in Vernon Watkins’ vital signs throughout the scenario. Pt. initial SP02 read 91% on room air upon initiating 02 therapy pt SP02 rose to 93% and Pt condition improved. Pt seemed more at ease with decreased anxiety noted. Rate and quality remained unchanged after treatment RR 24 with equal chest rise and fall. Pt heart rhythm and rate remained at 110. 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 patient, a general impression of the patient was obtained. The patient was complaining of breathing difficulty. Patient was positioned upright to facilitate the breathing and spo2 level was obtained with 3 lead ECG monitoring attached, tachycardia was noted, equal chest rise and fall , lung sounded clear and equal bilaterally, spiral CT of chest, chest x ray, venous blood sample and ABG sample were taken, Heparin iv bolus given and per hour in D5W Maintenance drip, patient vital sign were continuously obtained while taking patient history. Patient stated he had chest pain at a 3 out of 10 of pain scale and his right leg was hurting.

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