Linda Waterfall Documentation .WELL EXPLAINED 100% CORRECT.

1. Document your findings related to the focused assessments of Ms. Waterfall’s signs and symptoms of respiratory and/or cardiac distress. Include her responses to your assessment. Ms. Waterfall’s s/s included increased ...

1. Document your findings related to the focused assessments of Ms. Waterfall’s signs and symptoms of respiratory and/or cardiac distress. Include her responses to your assessment. Ms. Waterfall’s s/s included increased anxiety and she reports SOB related to cardiac/respiratory distress. She states, “I feel like I’m going to die,” and “I don’t feel chest pain but my chest feels heavy.” 2. Document your findings related to the focused assessment of Ms. Waterfall’s signs and symptoms of acute anxiety. Include her responses to your assessment. Ms. Waterfall shows signs of concern, worry, anxiety, dread, and restless nights related to past experiences that were traumatizing to her related to her mother’s death from surgical complications. Ms. Waterfall needs her “medicine bundle” that she left at home. This is important to her related to her religious and cultural beliefs. She does not want to have surgery without her medicine bundle. Ms. Waterfall doesn’t have a high support system due to her family living far away. Ms. Waterfall is accompanied by her cousin, Alice. 3. Referring to your feedback log, document all nursing care provided and Ms. Waterfall’s response to this care. Upon entering room, the scene was observed to maintain safety, washed hands, and Pt was identified by first and last name and DOB. Pt was asked for consent on her cousin, Alice being present in the room during any questions> Pt became upset with the thought of her family member leaving. Pt was reassured that she would not be left alone. Pt VS were assessed and all within normal range. Pt asked if she is having any chest pain or trouble breathing; Pt reports no pain but she feels like she is going to die and she can’t catch her breathe . Breathing exercises were taught and educated on deep breathing. It was explained that she is safe here. Pt was offered the pre-op medication of Lorazepam 2 mg. Pt refused medication. Pt continues to stay anxious as she has stated that she left her “medicine bundle” at home, this is of high importance and within her religion. 4. Document all interventions associated with the management of Ms. Waterfall’s anxiety as they are included into her plan of care. Include interventions especially focused on her spiritual and cultural needs, as well as those demonstrating nursing advocacy. Pt refused ordered pre-op medication, 2 mg Lorazepam to alleviate anxiety. Pt was educated on deep breathing techniques and participated in exercises. Pt was unable to fully relax due to her medicine bundle not being with her. Medicine bundle is vital relating to spiritual and cultural beliefs. Pt educated that she has the choice to postpone surgery until she feels necessary. Pt remains anxious, uncertain, and worried r/t surgery, medicine bundle missing. Notified Dr. Samuels about postponing surgery until Pt deems necessary to continue and is in calmer state. 5. Document your handoff report in the SBAR format to communicate Ms. Waterfall’s future needs. Linda Waterfall, 48 year old Native American female, IV infusion 18G in R forearm at 80mL/hr. Pt is A&O X4. Pt diagnosed with breast cancer, Surgeon is Dr. Samuels. Pt was scheduled for L mastectomy at 0830, surgery is being rescheduled as Pt did not have her medicine bundle. This spiritual belief is vital to her religious beliefs as she is Native American. Pt educated that it is her right to delay surgery until she feels more comfortable moving forward with surgery. Pt remains anxious, uncertain, and unsure after interventions were implemented. Surgeon was notified of the Pt’s desire to postpone surgery and provider was called. Pt wants medicine bundle before surgery is considered due to culture and it being a strong spiritual ritual for Native American heritage. Pt continues to be anxious and uncertain without medicine bundle. Pt shows sign of concern relating to surgery because of her mother dying from surgical complications. Pt refused pre-op administration of Lorazepam. Family/friends need to retrieve medicine bundle prior to surgery. Education was provided about deep breathing to aid her in finding a calmer mindset. Pt has been NPO since midnight, Pt needs tray of food if surgery remains rescheduled.