Surgical Case 4: Vernon Watkins
Documentation Assignments
1. Document Vernon Watkins’ respiratory assessment that occurred in the case.
Pt. breathing with equal chest rise and fall, lung sounds clear and equal bilater
...
Surgical Case 4: Vernon Watkins
Documentation Assignments
1. Document Vernon Watkins’ respiratory assessment that occurred in the case.
Pt. breathing with equal chest rise and fall, lung sounds clear and equal bilateral. Pt RR
24 Pt is speaking in full sentences however, Pt appears anxious with increased work of
breathing. SP02 read 90% on room air. Pt states that it is painful to breath Pt rates pain
at 3 out of 10 on the pain scale.
2. Document the actions during the acute respiratory distress episode.
Upon completing Pt respiratory assessment Pt was assisted to the sitting position to
better Pt breathing. 02 was started 15lpm via non rebreather mask, and the provider
was advised of the change in the patient’s condition. The provider ordered a 12 lead
EKG, chest Xray, Spiral CT of Pt chest, ABG, venous blood sample. 6400 units of heparin
were given IV bolus and a maintenance drip of heparin was started in D5W rate 1440
units per hour. Pt was continuously monitored every 5 min for vitals sign changes and for
new orders from the provider.
3. Document the changes in Vernon Watkins’ vital signs throughout the scenario.
Pt. initial SP02 read 90% on room air upon initiating 02 therapy pt SP02 rose to 94% and
Pt condition improved. Pt seems more at ease with decreased anxiety noted. Pt
breathing rate and quality remained unchanged after treatment RR 24 with equal chest
rise and fall. Pt heart rhythm and rate remained sinus tach rate 102. Pt is still
complaining of pain when breathing and leg pain.
4. Identify and document key nursing diagnoses for Vernon Watkins.
Impaired gas exchange related to ventilation-perfusion imbalance as evidenced by
dyspnea, restlessness and apprehension.
5. Referring to your feedback log, document the nursing care you provided.
[Show More]
.png)
