Mrs. Kaur has been feeling unwell. She has been complaining of harsh productive coughing, producing thick greenish yellow sputum. Coughing worsens when lying down, and sometimes, the coughing is so constant, that she feels like her ribs are breaking. She feels extremely short of breath, and any exertion causes her to lose her breath. She stops more frequently while walking to catch her breath, as she feels she is “Unable to breathe at times”. She says that she feels like her chest is full, and when she tries to take deep breaths, it hurts. She became dizzy when she was walking from her bedroom to the bathroom yesterday, and in her haste to sit down for fear of passing out, she stubbed her toe, which is now bruised and swollen. Vital signs were assessed one hour ago; temp is 37.5C orally, heart rate 99 beats per minute, strong and regular, respiratory rate 22, shallow, and SOB upon exertion, BP 130/90 mmHg, and SpO2 95% on room air.
Doctor’s Orders:
Complete a set of Vital Signs
Complete a Pain Assessment
Complete a focused Respiratory Assessment
Complete an Integumentary Assessment
Objectives:
Complete the appropriate assessments.
Complete your Narrative documentation on a Client Care Record and document your findings on the appropriate documentation Flow Sheets.