Documentation Assignments 1. Document your focused assessment of Mona Hernandez. My focused assessment of Mona Hernandez is that the patient has pneumonia with diminished lung soungs of the right lo... wer lobe. She has a cough and is having difficulty breathing. I provided oxygen therapy to help her breath easier and increase her oxygen saturation level. This intervention helped improve her condition. 2. Document your education to Mona Hernandez regarding the purpose of, and how to use, 3. Document your assessment findings and any nursing interventions related to Mona Hernandez’s oxygenation after ambulation. Patient is having difficulty breathing and pain with breathing. I adjusted the patient to a high sitting position and encouraged her to cough. I also had the patient use an incentive spirometer. I then gave the patient oxygen to help increase her Oxygen saturation level. I then increased the oxygen and switched from a nasal cannula to a simple mask. Then I switched to a non rebreather mask since her stats were still not in the normal range. The non-rebreather mask then boosted her oxygen saturation level. the incentive spirometer. 3I educated the patient that the incentive spirometer is a device that will expand your lungs by helping you to breathe more deeply and fully. I also told the patient to use one they must: Sit upright in a chair or in bed. Hold the incentive spirometer at eye level. Put the mouthpiece in your mouth and close your lips tightly around it. Slowly breathe out (exhale) completely. Breathe in (inhale) slowly through your mouth as deeply as you can. As you take the breath, you will see the piston rise inside the large column. While the piston rises, the indicator on the right should move upwards. Try to get the piston as high as you can, while keeping the indicator between the arrows. When you get it as high as you can, hold your breath for 10 seconds, or as long as possible. Once the piston reaches the bottom of the spirometer, breathe out slowly through your mouth. Rest for a few seconds. Repeat 10 times. Try to get the piston to the same level with each breath. After each set of 10 breaths, try to cough, holding a pillow over your incision, as needed. Coughing will help loosen or clear any mucus in your lungs. 4. Referring to your feedback log, document the nursing care you provided to Mona Hernandez and her response. I provided oxygen therapy to help her breathe easier. I also had her use an incentive spirometer. She did show improvement with her oxygen saturation level and her breathing became easier after oxygen therapy. [Show More]
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