Vince Brody - Respiratory Assessment

Vince Brody Documentation Assignments 1. Document your focused respiratory assessment for Vincent Brody. Focus on respiratory rate, lung sounds, chest movement, and oxygen saturation for preventing hypoxemia. The initial assessment: Respiration rate: 21, SpO2: 93%, a few audible wheezes in the chest, the chest is moving normally on both sides. Patient stated, “This cough is killing”, When the patient developed a left-sided pneumothorax, there were reduced breath sounds on the left side while there’re breath sounds on the right side. After administered morphine, watch for respiratory distress. 2. Identify and document key nursing diagnoses for Vincent Brody. DX#1 ineffective breathing pattern r/t COPD AEB tachypnea. DX#2 acute pain r/t chest tube insertion AEB patient complaints of pain. DX#3 Risk of infection r/t chest tube insertion 3. Document pain management interventions and Vincent Brody’s response to therapy. Administered 2 mg dose of morphine intravenously before placing a chest tube. Patient tolerated well, without showing respiratory distress symptoms. 4. 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- hour intervals. Drainage: notify the HCP if drainage is more than 70 to 100 mL/hour or if drainage becomes bright red or increases suddenly Fluctuation: fluctuation stops if the tube is obstructed. Air Leak: continuous bubbling indicates an air leak in the system, notify the HCP. 5. Referring to your feedback log, document the nursing care you provided. A. maintain patient safety with washing hands, identifying the patient (patient states her name and DOB), asking allergies (no known allergies). B. check patient’s vital signs) and pain level; C. assess IV sites (no redness, swelling, infiltration, bleeding, or drainage, dressing was dry and intact) D. auscultate sound of lungs (normal), heart (normal) E. Attach the pulse oximeter and 3-lead EKG to patient. F. When the patient developed pneumothorax, provided patient with 100% oxygen from a nonrebreathing mask, contacted HCP. G. slowly Administer 2 mg dose of morphine via IV before chest tube insertion H. obtain informed consent, and assist physicians inserting a chest tube I. request a chest x-ray to make sure the tube is in the right place. J. give patient education. K. A patient handoff was performed. Guided Reflection Questions 1. How did the scenario make you feel? This scenario made me feel comfortable and it helped a lot that the patient was cooperative and willing to answer questions regarding his condition. 2. When a patient develops a rapid onset of shortness of breath, what are the nurse’s immediate priorities? Assessing patent airway and breathing is the number one priority. If the patient needs any oxygen, provide while contacting the physician. It is vital to sit the patient upright and identify the reason for his shortness of breath and addresses it. Next is to auscultate the lungs for presence of any abnormal sounds like crackles, wheezing, or absent breath sounds. 3. What assessment findings would indicate that the patient’s condition is worsening? Various things can point to a condition worsening for example, SaO2 dropping, confusion and drowsiness, changes in color like cyanosis in lips or fingernails, pallor in skin tone. Changes in lung sounds, patient reporting chest tightness or shortness of breath. 4. Review Vincent Brody’s laboratory results. Which results are abnormal? Discuss how these results relate to his clinical presentation and chronic disease process. The patient’s Arterial Blood Gas came back with an elevated HCO3 and PCO2 but the pH was within normal range. The patient may be experiencing respiratory alkalosis, this may have the patient have seizures, numbness and tingling, hypokalemia, hyperventilation, confused and tachycardia. The patient also had a high hematocrit which is commonly found in patients with COPD. 5. What are safety considerations when caring for a patient with a chest tube? Checking the patient’s respiration rate, breath sounds, and oxygen saturation as much as possible. Inspect the dressing and note any drainage present be sure to include the color, consistency and odor. Make sure that the tubing does not have any kinks. Assess the skin surrounding the chest tube for any tenderness, redness or swelling. 6. What key elements would you include in the handoff report for this patient? Consider the SBAR (situation, background, assessment, recommendation) format. S: Vincent Brody is a 67-year-old male admitted directly from the provider's ofÏce several hours ago for exacerbation of COPD. B: Vincent Brody was having been treating for exacerbation of the COPD. He is maintaining 02 saturations on 2 L/min of oxygen per nasal cannula. IV of potassium chloride in 5 dextrose and normal saline is infusing at 100 mL/nr in his right arm. He has responded well to medications and treatments and appears to be resting. He was treating with Iv potassium chloride in 5% dextrose and normal saline at 100 mL/hour in his right hand. He has barred chest and sign of clubbing nails. A: The patient vital signs were the following: HR-21, BP: 198/80, Resp: 23, SpO2: 94%, and Temp-99F.ECG monitoring that shows sinus tachycardia. Arterial blood gas drawn indicate was: PH-7.40, HCO3- 26.3, and PaCO2- 49. He was administered albuterol 2.5mg in 3mL normal saline via nebulizer every 20 minutes x 3 doses. Suddenly patient complained of chest pain, on auscultation lung area, there is indication of a possible pneumothorax. Provider came in to put in place a chest tube. R: Continue to monitor the chest tube and vital signs, reinforce patient education, and if any changes occur, notify the provider. 7. What patient teaching priorities would be important in the patient experiencing an acute exacerbation of COPD? It’s important to teach breathing exercises like deep breathing. The importance of Smoking cessation, nutrition and ambulating to avoid further complications. 8. For a patient with COPD who is stable, what resources would you recommend? I would recommend is participating in smoking cessation programs, because it is essential to quit smoking. I would also recommend them to looking into the American lung association, COPD foundation, and if the family wants any support the family caregiver alliance. 9. What would you do differently if you were to repeat this scenario? How would your patient care change? I do not think I would change anything I did in this scenario as in the way of care. What I would change is maybe reacting faster to the patient’s needs. SBAR S: Vincent Brody is a 67-year-old male admitted directly from the provider's ofÏce several hours ago for exacerbation of COPD. B: Vincent Brody was having been treating for exacerbation of the COPD. He is maintaining 02 saturations on 2 L/min of oxygen per nasal cannula. IV of potassium chloride in 5 dextrose and normal saline is infusing at 100 mL/nr in his right arm. He has responded well to medications and treatments and appears to be resting. He was treating with Iv potassium chloride in 5% dextrose and normal saline at 100 mL/hour in his right hand. He has barred chest and sign of clubbing nails. A: The patient vital signs were the following: HR-21, BP: 198/80, Resp: 23, SpO2: 94%, and Temp-99F.ECG monitoring that shows sinus tachycardia. Arterial blood gas drawn indicate was: PH-7.40, HCO3- 26.3, and PaCO2- 49. He was administered albuterol 2.5mg in 3mL normal saline via nebulizer every 20 minutes x 3 doses. Suddenly patient complained of chest pain, on auscultation lung area, there is indication of a possible pneumothorax. Provider came in to put in place a chest tube. R: Continue to monitor the chest tube and vital signs, reinforce patient education, and if any changes occur, notify the provider.