VSIM Hoffman Guided Reflection Questions

VSIM : JENNIFER HOFFMAN Medical Case 2: Jennifer Hoffman Guided Reflection Questions 1. How did the scenario make you feel? I felt like this scenario make me prepare during someone experiencing asthma attack. I feel like I know what to do , how to do it and the steps need to take. 2. What assessment findings would indicate that the patient’s condition is worsening? If the Spo2 of the patient didn’t reach above 92% then the ABG came back as respiratory acidosis. 3. When a patient develops a rapid onset of shortness of breath, what are the nurse’s immediate priorities? To keep the airway patent, to keep SPO2 as high as possible and to keep the patient calm. 4. Review Jennifer Hoffman’s laboratory results. Identify which results are abnormal and discuss how this relates to her clinical presentation and the disease process. SPo2-78% : this is abnormal because the asthma can cause the bronchoconstriction and bronchial edema, that makes it harder for patient on expiration and in inspiration which would bring the SPO2 down and her Co2 up. HR: 130’s : it is abnormal because the heart is pumping really fast as the body is not receiving enough oxygen and the o2 demands is very high in the body. 5. What communication techniques are important for an extremely anxious patient who is having difficulty breathing? It is important for the nurse to remain calm. Even when the patient explained that she can’t breathe, I felt nervous but was I stayed focused and administer the proper medication as prescribed. 6. What patient teaching priorities would be important for the patient who has experienced an acute exacerbation of asthma? Teaching about their medication and how it is used . 7. What resources would you recommend for the patient experiencing asthma? Asthma care plan would be very helpful for someone who has aasthma. 8. What would you do differently if you were to repeat this scenario? How would your patient care change? I would first check the vital sign when patient explain that she cannot breathe. And after assessing her pulse rate and respiratory rate , I would immediately give the medication to improve the patient breathing pattern and to keep that airway patent. Medical Case 2: Jennifer Hoffman Documentation Assignments 1. Document your initial focused respiratory assessment of Jennifer Hoffman. Patient appears to be on respiratory distress thus my focused respiratory assessment was taking her vital sign. I checked her pulse oximetry, her heart rate and determines what needs to be done for patient. I auscultate her lung sounds to determine the wheezing. 2. Identify and document key nursing diagnoses for Jennifer Hoffman. Ineffective breathing pattern, related to swelling and spasm of the bronchial tubes as evidence by cough, tachypnea and using of accessory muscle. Activity intolerance Anxiety Ineffective airway clarence Deficient knowledge. 3. Referring to your feedback log, document the nursing care you provided. Assessed Vital sign and IV. Monitor Spo2, ECG very closely Provide comfortable position assisting for he is breathing Consistent monitoring for her respiratory status. Provide education O2 administration by use of non- rebreather mask to maintain Spo2>92% Administer meds including Albuterol, methylprednisolone and ipratropium. Chief Complaint: Aasthma Labs/Diagnostics: ABGs Indicating Respiratory Acidosis Patho for main Medical Diagnosis: What am I? Asthma What causes me? Allergies, in this case of patient, it may cause by Hay Fever. What are the S&S of me? Shortness of breath, dyspnea, tachypnea, cough, wheezing, Clinical Findings starting with VS, then list assessment: SPo2: 74% Heart Rate: 120 Blood pressure : 136/81 Respiration : 25 Age/Sex: 33y.o/ F Admit date:10/16/2020 DOC/LOS: Allergies/BMI: Hay fever PMH & HX Current Illness: Patient has history of asthma and now admitted for acute asthma exacerbation. Multiple ER visit. AssaAs NURSING INTERVENTIONS Current Med. List (brand & generic): Albuterol Methylprednisolone Ipatropium Home Meds: Assessment Check vitals like respiration rate, pulse oximetry, blood pressure, temperature and heart rate. Auscultate lungs sounds Comfortable position: High Fowler position. Therapeutic (Admin Meds, Patient Problems Patient cannot breath and is very tired of trying to breathe. Education: POC Educate about the patient medical regimen. How to use the medication with nebulizer or with the Dry powder inhaler. Educate about the timing of the. Medication and what actions need to be taken while experiencing acute exacerbation of asthma.