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vSIM Vernon Watkins - Post-op Hemicolectomy: Pulmonary Embolism / Surgical Case 4: Vernon Watkins Documentation Assignments (answered) $8.49   Add to cart
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vSIM Vernon Watkins - Post-op Hemicolectomy: Pulmonary Embolism / Surgical Case 4: Vernon Watkins Documentation Assignments (answered)

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vSIM Vernon Watkins - Post-op Hemicolectomy: Pulmonary Embolism / Surgical Case 4: Vernon Watkins Documentation Assignments (answered) Surgical Case 4: Vernon Watkins Documentation Assignments 1. Document Vernon Watkins’ respiratory assessment that occurred in the case. 2. Document the ac...

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  • February 25, 2021
  • 3
  • 2020/2021
  • Other
  • Unknown

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  • vernon watkins post op hemicolectomy pulmonary embolism

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Surgical Case 4: Vernon Watkins
Documentation Assignments
1.Document Vernon Watkins’ respiratory assessment that occurred in the case. Pt. breathing with equal chest rise and fall, lung sounds clear and equal bilateral. Pt RR 24 Pt is speaking in full sentences however, Pt appears anxious with increased work of breathing. SP02 read 90% on room air. Pt states that it is painful to breath Pt rates pain at 3 out of 10 on the pain scale.
2.Document the actions during the acute respiratory distress episode. Upon completing Pt respiratory assessment Pt was assisted to the sitting position to better Pt breathing. 02 was started 15lpm via non rebreather mask, and the provider was advised of the change in the patient’s condition. The provider ordered a 12 lead EKG, chest Xray, Spiral CT of Pt chest, ABG, venous blood sample. 6400 units of heparin were given IV bolus and a maintenance drip of heparin was started in D5W rate 1440 units per hour. 3.Document the changes in Vernon Watkins’ vital signs throughout the scenario. Pt. initial SP02 read 90% on room air upon initiating 02 therapy pt SP02 rose to 94% and Pt condition improved. Pt seems more at ease with decreased anxiety noted. Pt breathing rate and quality remained unchanged after treatment RR 24 with equal chest rise and fall. Pt heart rhythm and rate remained sinus tach rate 102. Pt is still complaining of pain when breathing
and leg pain.
4.Identify and document key nursing diagnoses for Vernon Watkins. Impaired gas exchange related to ventilation-perfusion imbalance as evidenced by dyspnea, restlessness and apprehension
5.Referring to your feedback log, document the nursing care you provided. Upon speaking to Pt a general impression of the patient was obtained. The patient was complaining of difficulty in breathing while I washed my hands and obtained consent to treat. Pt was positioned upright to facilitate breathing and an SP02 reading was obtained with 3 lead ECG
monitoring attached. SP02 read 90% on room air and a sinus tach rhythm on monitor was noted rate 106 Pt RR was noted to be 24 with equal chest rise and fall lung sounds clear and
equal bilateral. 02 was administered per Dr standing orders at 15lpm via non rebreather mask. The provider was notified of the Pt difficulty in breathing. The provider ordered a 12 lead ECG, spiral CT of the chest, a chest Xray, venous blood sample, ABG, Heparin 6400 units
loading bolus and 1440 units/hour in D5W maintenance drip. Pt vitals and pain were monitored continuously while obtaining further Pt Hx. Pt has medical Hx of HTN and smoking a half pack per day X50 years. Pt states that pain began suddenly in his chest and rates the pain 3 out of 10 Pt also states that his leg hurts. Head to toe Pt assessment reveals
that Pt leg appears to be swollen and is painful. © Wolters Kluwer Health | Lippincott Williams & Wilkins

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