University:
Saint Francis University
Course:
NURS300 | Fundamentals of Nursing
Academic year:

2023
Views:

375

Pages:

2
Author:

Zackery Vincent

Mona Hernandez Documentation Assignments 1. Document your focused assessment of Mona Hernandez. - Focused on the respiratory system. Patient is a 72 year old female admitted in for pneumonia. No allergies. She is experiencing shortness of breath and sharp pain in her right side when she coughs. Lungs sounds were diminished in the right lower lobe but no crackles or wheezing present. Patient O2 levels dropped to 88% and heart rate was elevated to 113 bpm. Temperature was elevated to 101 amd respirations were 21. She stated her pain was a 1. Patient was breathing heavily. Administered oxygen through a nasal canula at 5L and raised the bed into high-fowlers position. Oxygen level was raising up to a 95 now. Pulse dropped down to 107 and respirations were 17. Patient was sitting comfortably. 2. Document your assessment findings and any nursing interventions related to Mona Hernandez’s oxygenation after ambulation. - Her oxygen level was 88% so I raised the head of the bed and administered a nasal canula at 5L. I assessed her pain from a scale of 1-10 with her response being a 1. I educated her on oxygen therapy and how it can help her. I asked how her cough has been and when it started. It was a wet rusty color sputum for the past couple days. I had her cough multiple times into a basin, as well as use the spirometer. I educated her on the use of a spirometer. 3. Document your education to Mona Hernandez regarding the purpose of, and how to use, the incentive spirometer. -The purpose of using a spirometer is a visual reinforcement of deep breathing and encourages patient to maximize lung inflation and prevent ot reduce atelectasis. It also helps to support optimal has exchange and clearing of secretions. Pt is to inhale slowly and deeply 4. Referring to your feedback log, document the nursing care you provided to Mona Hernandez and her response. - I reviewed the patients information and then introduced myself . I washed my hands and asked for indentification from the patient. I then examined the patients chest and assessed her breathing, she was breathing at 21 breaths per minute. I assessed the patients mucous membranes. I then listened to the patients lungs and heart. I assessed the patients O2 levels and attached a pulse oximeter. I checked the patients radial pulse, temperature, blood pressure. I assisted the patient in a high sitting position. I encouraged the patient to cough and to deep breath to help expand her lungs. Then as ordered the patient used an incentive spirometer. I then assessed the patients breathing and her O2 levels. Her O2 levels were raised to 95%. I asked her if she was in any pain and she stated her pain was a 1 on a 1-10 scale. I asked her to describe her coughing and if it is wet or dry. She said there has been quite a lot to cough up the last couple days and that is it worse in the morning. I applied oxygen via a nasal cannula at 5L. I went into educating the patient about her medicatons that she was using, the use of a spirometer, oxygen therapy, what pneumonia is and asked about her diet. . I encouraged the patient to cough into the basin and use the spirometer multiple times. I assessed the sputum that was coughed up as a rusty color. The patient stated it has been like that for a couple days.

V-Simulation Assignment for Course Point

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