Mona Hernandez Documentation Assignments 1. Document your focused assessment of Mona Hernandez. V.S. ECG: sinus tachycardia HR: 119 Pulse: present BP: 149/88 RR: 21 SpO2: 88% Temp: 38.1 C States “ I have difficulty breathing. I am tired, with chest tightness”. States “I cough up a lot the last couple of days and it’s worse in the morning”. Chest moving equally. Flushed skin is warm and dry. Reduced breath sounds at right lung base. 2. Document your assessment findings and any nursing interventions related to Mona Hernandez’s oxygenation after ambulation. Educated pt. on oxygenation therapy. Provided warm humidified O2 at 2L. Pain 1 out of 10. High sitting position. Pt. SpO2 improved to 92 titrated to 6L. SpO2 at 95% 3. Document your education to Mona Hernandez regarding the purpose of, and how to use, the incentive spirometer. An incentive spirometer assist a patient to breath slowly and deeply. This allows you to sustain maximal inspiration. The gauge on the spirometer allows a pt. to visualize inspiration goals and measure progress. This tool allows a person to maximize lung inflation and to reduce/prevent atelectasis (collapse or partial collapse of the lungs). The incentive spirometer also helps to clear secretions and allows for optimal gas exchange. 4. Referring to your feedback log, document the nursing care you provided to Mona Hernandez and her response. I think the priority for this patient was to monitor her oxygen levels, vitals, and ensure she was coughing and using her incentive spirometer. During the scenario various methods were used to manage her care. The first was to put the patient in a high seating position to improve her breathing. Next, the SpO2 monitor was used to monitor her O2 saturation. Next, I assessed her RR, and ask if it was difficult for her to breath. Next the patient was educated on the use of O2 and she was given a nasal cannula. The O2 was titrated to 6L were the patient O2 level stabilized to 95%. The patient was also educated and instructed on coughing. During this intervention, the pt. produced sputum with rust color. The patient was also educated on the use of her incentive spirometer. The pt. demonstrated understanding and used her incentive spirometer effectively.

Mona Hernandez Documentation Assignment

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