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Complete Solution on vSim for Nursing | Medical-Surgical

MEDICAL SCENARIOS FOR JENNIFER HOFFMAN

  1. Document your initial focused respiratory assessment of Jennifer Hoffman.
  2. Identify and document key nursing diagnoses for Jennifer Hoffman.
  3. Referring to your feedback log, document the nursing care you provided.

Answer

  1. Document your initial focused respiratory assessment of Jennifer Hoffman.

Patient appeared to be in respiratory distress, struggling to breathe, she is unable to speak other that single one word statement. Her heart rate is 29, breaths per minutes, with increased respiratory effort, using of accessory muscles. There is a lot of audible wheezing in the chest, SpO2 78, and cough

  1. Identify and document key nursing diagnoses for JENNIFER HOFFMAN.

Ineffective breathing pattern related to swelling and spasm of the bronchial tubes as evidenced by cough, tachypnea, using of accessory muscles, wheezing in the chest, decreased SpO2, ineffective airway clearance, anxiety, activity intolerance, and deficient knowledge.

  1. Referring to your feedback log, document the nursing care you provided.

-I washed my hands.

-I identified the patient.

-I provided patient education.

-I attached the pulse oximeter.

-I examined the patient’s chest. She is breathing at 31 breaths per minute. There is a lot of audible wheezing in the chest. There is increased respiratory effort. There is normal skin turgor. Her skin is blue.

-I examined the patient’s legs. There is nothing to find on examination of the legs.

-I listened to the lungs of the patient. There is a lot of audible wheezing in the chest.

-I listened to the heart of the patient. The pulse was irregular, but there were no abnormal heart sounds.

-I looked for normal breathing. She is breathing at 30 breaths per minute. There is a lot of audible wheezing in the chest. There is increased respiratory effort.

-I checked the radial pulse. The pulse is strong, 100 per minute and irregular.

-I measured the blood pressure at 114/66 mm Hg.

-I checked the temperature at the mouth. The temperature was 99 F (37 C).

-I checked the patient’s pupils, and they were 5 mm and reactive.

-I checked the radial pulse. The pulse is strong, 100 per minute and irregular.

-I checked the carotid pulse. The pulse is strong, 100 per minute and irregular.

-I attached the automatic noninvasive blood pressure (NIBP) measurement cuff.

-I attached a 3-lead ECG. It is correct to attach the monitor to the patient.

-I assessed the patient’s IV. The site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact.

-I phoned the provider in order to discuss the patient.

-I placed a 5 mg dose of albuterol in a nebulizer.

-I examined the patient’s chest. She is breathing at 24 breaths per minute. There are a few audible wheezes in the chest. The chest is moving normally on both sides. There is normal skin turgor. Her skin is cool, and she is very sweaty.

-A patient handoff was performed.

 

Description

Complete Solution on vSim for Nursing | Medical-Surgical

Patient Introduction

Kenneth Bronson is a 27-year-old male who was just admitted to the Medical Unit from the Emergency Department. He presented to the Emergency Department two hours ago with chest tightness, difficulty breathing, a productive cough for a week, and fever. Chest x-ray revealed right lower lobe pneumonia. IV was started of normal saline at 75 mL per hour. He is receiving oxygen at 2 L/min per nasal cannula. SpO2 on room air was 90%, which increased to 95% with supplemental oxygen. He had a temp of 102.6°F and was given acetaminophen 1,000 mg in the Emergency Department. Pharmacy just delivered the antibiotics to be given.

Feedback Log

0:00     You arrived at the patient’s side.

0:00     You introduced yourself.

0:09     You washed your hands. To maintain patient safety, it is important to wash your hands as soon as you enter the room.

1:24     You identified the patient. To maintain patient safety, it is important that you quickly identify the patient.

1:39     You provided patient education. This is correct. It is important to use every opportunity to provide patient education.

1:53     You asked the patient if he had any pain. He replied: ‘Yes, I have some pain.’

1:56     You asked the patient if anything made the pain better. He replied: ‘No, not really.’

2:01     You asked the patient if anything made the pain worse. He replied: ‘It hurts a bit when I breathe.’

2:05     You asked the patient if he could describe his pain. He replied: ‘It stings a bit in my chest.’

2:08     You asked the patient where the pain was located. He replied: ‘It’s in the right side of my chest.’

2:11     You asked the patient if the pain went anywhere. He replied: ‘No, not really.’

2:16     You asked: How bad is the pain? He replied: ‘Not too bad, it’s about a 2.’

2:24     You asked the patient how long he had pain for. He replied: ‘For about a week.’

2:32     You asked the patient if the pain was better after the medication. He replied: ‘It’s the same.’

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MEDICAL SCENARIOS FOR VINCENT BRODY

  1. Document your focused respiratory assessment for Vincent Brody.
  2. Identify and document key nursing diagnoses for Vincent Brody.
  3. Document pain management interventions and Vincent Brody’s response to therapy.
  4. Document key assessments you would monitor for a chest tube (insertion site, dressing, suction level, drainage, fluctuation, air leak).
  5. Referring to your feedback log, document the nursing care you provided.

Answer

  1. Document your focused respiratory assessment for V incent Brody.

I focused on respiratory rate, lung sound, chest movement, oxygen saturation for preventing hypoxemia, The initial assessment respiratory rated , 21, SpO2;93%, a few audible wheezes in the chest, the chest is moving normally on both sides, Patient stated the cough is killing. When the patient developed left sided pneumothorax, there were reduced breaths sounds on the right side. After administered morphine, watch for respiratory distress

  1. Identify and document key nursing diagnoses for Vincent Brody.

-Ineffective breathing pattern related to COPD as evidenced by tachypnea

-Acute pain related to chest tube insertion as evidenced by patient complains of pains

-Risk of infection related to chest tube insertion

  1. Document pain management interventions and Vincent Brody’s response to therapy.

I administered 2 dose of morphine intravenously before placing a test tube. Patient tolerated very well without showing respiratory distress symptoms

  1. Document key assessments you would monitor for a chest tube (insertion site, dressing, suction level, drainage, fluctuation, air leak).

Insertion site; an occlusive sterile dressing is maintained at the insertion site .

Dressing; occlusive type

Suction Level; mark the chest tube suction level at 1 to 4 hours intervals

Drainage; notify the HCP if drainage becomes bright red or increases suddenly.

Fluctuation; fluctuation stops if the tube is obstructed

Air leak; continuous bubbling indicates an air leak an air leak in the system, notify the HCP

  1. Referring to your feedback log, document the nursing care you provided.

-I washed your hands.

-I identified the patient.

-I sat the patient up. It is correct to do so.

-I provided patient education.

-I examined the patient’s chest. He is breathing at 21 breaths per minute. There are a few audible wheezes in the chest. The chest is moving normally on both sides. There is normal skin turgor. His color is normal, and he is not sweating.

-I examined the patient’s legs. There is normal skin turgor. His color is normal, and he is not sweating. There is nothing else to find on examination of the legs.

-I listened to the lungs of the patient. There are a few audible wheezes in the chest.

-I listened to the heart of the patient. There were only normal heart sounds.

-I attached the pulse oximeter.

-I checked the radial pulse. The pulse is strong, 105 per minute and regular.

-I measured the blood pressure at 128/76 mm Hg.

-I checked the temperature at the mouth. The temperature was 99 F (37 C).

-I attached a 3-lead ECG. It is correct to attach the monitor to the patient.

-I assessed the patient’s IV. The site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact.

-I listened to the lungs of the patient. There are reduced breath sounds on the left side. There are breath sounds on the right side.

-I listened to the lungs of the patient. There are reduced breath sounds on the left side. There are breath sounds on the right side.

-I placed a 2.5 mg dose of albuterol in a nebulizer. It was correct to administer a bronchodilator here. It is important to use the basic rights of medication administration to ensure proper drug therapy.

-I attached the automatic noninvasive blood pressure (NIBP) measurement cuff.

-I checked the pedal pulse. The pulse is strong, 115 per minute and regular.

-I checked the radial pulse. The pulse is strong, 120 per minute and regular.

-I checked the carotid pulse. The pulse is strong, 120 per minute and regular.

-I assessed the patient’s IV. The site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact.

-I obtained informed consent.

-I phoned the provider in order to discuss the patient.

-I assisted while the provider placed a chest tube.

-I requested a chest x-ray. This was correct

-I listened to the lungs of the patient. There are reduced breath sounds on the left side. There are breath sounds on the right side.

-I listened to the lungs of the patient. There are reduced breath sounds on the left side. There are breath sounds on the right side.

-I assessed the patient’s IV. The site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact.

-I listened to the lungs of the patient. There are reduced breath sounds on the left side. There are breath sounds on the right side.

-I listened to the lungs of the patient. There are reduced breath sounds on the left side. There are breath sounds on the right side.

-I listened to the lungs of the patient. There are a few audible wheezes in the chest.

-I phoned the provider in order to discuss the patient.

-A patient handoff was performed.