Jennifer Hoffman DA - Vsims PDF

Preview

Summary

Vsims...

Description

Medical Case 2: Jennifer Hoffman Documentation Assignments Document your initial focused respiratory assessment of Jennifer Hoffman. Pt has history of asthma, onset during childhood, triggers Poss “hay fever” Pt stated she is allergic, Pt is alert & oriented, SOB, agitated & restless w/ shallow bilateral breathing depth, RR25, Spo2-80% RA, audible wheezing in the chest. Identify and document key nursing diagnoses for Jennifer Hoffman.  Ineffective airway clearance related to increased production of mucus and bronchospasm  Impaired gas exchange related to impaired O2 delivery  Anxiety related to SOB/threat of death Referring to your feedback log, document the nursing care you provided.  Introduced myself  Washed hands  IDed Pt using two identifiers  Asked for Allergy status- Pt stated “Hey Fever”  Listened to Pt lungs  Attached Spo2 monitor  Attached NIBP for BP monitoring  Attached 3-lead ECG  Assessed Pt RR rate  Checked Pt temp  Place non-rebreather mask on @ 12L  Administered 5mg of albuterol in a nebulizer  Administered 500mcg of Ipratropium in a nebulizer  Assessed Pt IV site and Flushed  Administered 100mg of Methylprednisolone IVpush  Phoned the Provider using SBAR  Checked temp and RR  Listened to Pt lungs  Assessed Pt head to toe  Provided Pt education  Continued to monitor vital signs

© Wolters Kluwer Health | Lippincott Williams & Wilkins...