MEDICAL NURSING Documentation Assignments Hoffman
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Medical Case 2: Jennifer Hoffman Documentation Assignments 1. Document your initial focused respiratory assessment of Jennifer Hoffman. The initial focused respiratory assessment findings are the f ... ollowing: Sinus tachycardia. Heart rate: 117. Pulse: Present. Blood pressure: 133/79 mm Hg. Respiration: 25. Conscious state: Appropriate. SpO2: 78%. Temp: 99 F (37 C) 2. Identify and document key nursing diagnoses for Jennifer Hoffman. Some nursing diagnoses for Jennifer Hoffman are: 1) Ineffective breathing pattern related to asthma, 2) Anxiety related to asthma 3. Referring to your feedback log, document the nursing care you provided. Some of the nursing care that I provided were as following: I introduced myself Washed my hands Identified the patient to maintain patient safety Ask if patient is allergy to anything and also if she is in pain I did vital signs including placing 3-lead ECG and nasal oxygen cannula I administer doctors order of albuterol, Ipratropium, methylprednisolone, and normal saline IV © Wolters Kluw [Show More]
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