Medical Case 3: Vincent Brody
Documentation Assignments
1. Document your focused respiratory assessment for Vincent Brody.
Pt has SOB with coughing. Few audible wheezes, Sao2 is 93% w/ 02. After a coughing attack
the pt starts complaining that his DIB is getting worse w/ every breath and his Sa...
Medical Case 3: Vincent Brody Documentation Assignments
1. Document your focused respiratory assessment for Vincent Brody.
Pt has SOB with coughing. Few audible wheezes, Sao2 is 93% w/ 02. After a coughing attack the pt starts complaining that his DIB is getting worse w/ every breath and his Sao2 has dropped to 87% w/ 02. Pt then starts having diminished breath sounds on the left side. After chest tube is inserted for pneumothorax the pt starts getting better and regains breath sounds on the left side. 2. Identify and document key nursing diagnoses for Vincent Brody.
Impaired Gas exchange:
Ineffective airway clearance:
Risk prone health behavior:
Activity Intolerance:
3.Document pain management interventions and Vincent Brody’s response to therapy.
The pt received 2mg of Morphine IVP prior to the insertion of chest tube. The pt didn’t c/o any further pain when asked. The pt was given Albuterol 2.5mg w/o relief of symptoms. Pt later had a Chest tube inserted due to a pneumothorax. After insertion the pt was sent to xray to ensure that the cx tube was successful. The pt had a positive response to the insertion of cx tube, evidenced by a increase in Sp02, Breath sounds and relief of SOB to some extent. 4.Document key assessments you would monitor for a chest tube (insertion site, dressing, suction level, drainage, fluctuation, air leak).
Make sure that all tubes are patent and connected securely. Make sure that the water seal is intact and functioning properly.
Watch for drainage, and monitor the charteristic of drainage (color, amount, consistency odor). Any major increases or decreases in amount. Note any fluctuations in water seal.
Keep the system below the pt’s cx level.
Make sure that the suction control is attached and bubbling. Keep in at the prescibed level.
Maintain fluid at the right level in water seal chamber. Keep vent open when the suction is off. 5.Referring to your feedback log, document the nursing care you provided.
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