You are a Respiratory Therapist in the Emergency Department. A 36-year-old female accidentally slipped and fell while climbing a large pine tree. She fell backward for about 15 feet before being impaled by a broken tree limb about 15 feet above the ground. The jagged limb, which was about 3/2 inches in diameter, pierced her right posterior thorax between her spine and the medial portion of her scapula. The sharp, pointed end of the tree limb protruded out about a foot beyond the anterior portion of her chest. A friend called 911 immediately. With the tree limb still protruding out through her anterior and posterior thorax, she was transported to the regional university medical center via a medical helicopter. The patient had emergency surgery and the tree limb has been removed. The physician has asked you to do a complete patient assessment of the patient now.
A. Explain the steps of how you would do a complete patient assessment and explain the purpose of every step. What questions would you ask your patient?
During the initial patient assessment, you collected relevant information and conducted a thorough physical examination. Upon examination, her vital signs were a blood pressure of 105/55, a heart rate of 90/min regular but weak, a respiratory rate of 12 bpm, and a temperature of 101°F. Auscultation revealed wheezes and fine crackles over the right lung area. A hyperresonant percussion note on the right was noticed. Wheezes could also be heard over the patient's right lung. A history of asthma was documented in the patient's chart.
B. Complete a SOAP note using the information above.
