Medical Case 3: Vincent 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, Sp02: 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.
2. Identify and document key nursing diagnoses for Vincent Brody. ineffective breathing pattern due to COPD Risk for aspiration secondary to ineffective airway caused by COPD acute pain with chest tube insertion Risk of infection from chest tube insertion
3. Document pain management interventions and Vincent Brody's response to therapy. Administered 2 mg of morphine slow IV PUSH prior to chest tube insertion. Patient tolerated the procedure well and reported no pain
tt. Document your phone call to the provider, including the significant changes exhibited by Vincent Brody that triggered the need to notify the provider. Patient was having sudden chest pain and dyspnea and he had a stronger right sided breath sounds upon auscultation. This were signs of pneumothorax which made me call the provider. The provider ordered 2mg morphine, xray and chest tube placement.
5. Document key assessments i 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 tt- hour intervals Drainage: notify the HCP if drainage is more than 70 to 100 mLfthour 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. 6. Referring to your feedback log, document the nursing care you provided. I arrived at the patient's side. I introduced myself. I washed my hands. To maintain patient safety, it is important to wash my hands as soon as i enter the room.
@ Wolters Kluwer Health | Lippincott Williams & Wilkins
I identified the patient. To maintain patient safety, it is important that i quickly identify the patient.
I looked for normal breathing. He is breathing at 21 breaths per minute. There are a few audible wheezes in the chest. The chest is moving normally on both sides. I attached the pulse oximeter. It is a good idea to monitor the saturation and pulse here. This will allow me to reassess the patient continuously. I checked the radial pulse. The pulse is strong, 105 per minute and regular. It is correct to assess the patient's vital signs. I sat the patient up. It is correct to do so.
I measured the blood pressure at 128ft76 mm Hg. It is appropriate to monitor the patient by measuring the blood pressure. I checked the temperature at the mouth. T