Vernon Watkins DA - Vsims PDF

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Surgical Case 4: Vernon Watkins Documentation Assignments Document Vernon Watkins’ respiratory assessment that occurred in the case. Pt breathing is equal bilateral, lung sounds clear and equal bilateral. Pt RR 24 Pt is speaking in full sentences however, Pt appears anxious with increased work of breathing. SP02 read 91% on room air. Pt states that it is painful to breath, chest pain and leg pain Pt rates pain at 3 out of 10 on the pain scale. Document the actions during the acute respiratory distress episode. After completing the Pts respiratory assessment Pt was assisted to the sitting position to better Pt breathing. 02 was started @ 2L via nasal cannula, and the provider was notified of the changes. The provider ordered a 12 lead EKG, chest Xray, Spiral CT of Pt chest, ABG, venous blood sample. 1440 units of heparin were given IV bolus per order. Pt was continuously monitored every 5 min for vitals sign changes and for new orders from the provider. Document the changes in Vernon Watkins’ vital signs throughout the scenario. Pt SP02 read 91% on room air upon SP02 monitoring, started O2 @ 6L via NC and stable @ 92% and Pt condition improved. Pt breathing rate and quality remained unchanged after treatment RR 24 with equal chest rise and fall. Pt heart rhythm and rate remained sinus tacky rate 102. Pt is still complaining of pain when breathing and leg pain. Identify and document key nursing diagnoses for Vernon Watkins. Impaired gas exchange related to ventilation perfusion imbalance evidence by dyspnea and restlessness. Referring to your feedback log, document the nursing care you provided.  Introduce myself  Washed hands  ID Pt with two identifiers  Sat Pt up  Asked Pt if he had any allergies  Monitored Spo2, ECG and blood pressure  Head to toe assessment and vital signs  Assessed Pt dressings  Assessed for pain 3 out of 10  Placed Pt on O2 via NC @ 6L  Phoned Provider gave new orders 

Started infusing of heparin in dextrose 5% in water at 1440 U/hr

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Took labs on Pt and ABGs 12 lead ECG, normal sinus rhythm

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Requested CT scan and X-ray= Showed PE Phoned Provider with results Assessed Vital signs and assessed Gave Pt education Continued to monitor

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