Junetta Cooper Docu Assignment PDF

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Pharmacology Scenario 1: Junetta Cooper

Documentation Assignments 1. Document your assessment data of Junetta Cooper, including chest pain assessment (location, quality, severity, factors that make pain better/worse, associated symptoms: nausea, vomiting, or dizziness) and vital signs. Junetta Cooper 75 year old, African American female with 20 years in history of primary hypertension, that is controlled by medications. During the assessment she was experiencing chest pain the felt like a elephant was sitting on her chest. Beforer I gave her nitroglycerin for the chest pain her pain levels were a 6 out of 10 after checking her vitals her pulse 96 bpm, respiration 21 bpm, NIBP was 149/89 mm Hg, SpO2 was 96%, and her temperature was 99 F. After I gave her the medication she was able to calm down even though she still felt tightness in her chest but the pain was a level 1 out 10, pulse 88, BP 123/74, SpO2 96%, temperature 99 F, and RR 13. 2. Document patient education that you provided related to medication(s) administered during this scenario.  Nitroglycerin is a medication you take when you are having chest pain. When you experience chest pain, you place a tablet under your tongue. You can repeat this every 5 minutes for a total of three tablets. If you are still having chest pain after three tablets, you need to call 911.  Keep this medication (Nitroglycerin) in the container it comes in, tightly closed, and out of reach of children.  Place the sublingual tablet under your tongue and let it dissolve. The tablets should not be chewed, crushed, or swallowed. 3. Document medication(s) you administered during this scenario. During this scenario I administered two nitroglycerin 0.4 mg sublingual prn for the acute angina pain. 4. Document additional patient education you provided to Junetta Cooper during this scenario. I did educate her on drug interaction but she didn’t have medication that could interfere with each other. Again due to her condition if she didn’t take her medication as prescribed by her provider there could be some serious interaction involved.

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