Class notes
Jennifer Holfman VSIM
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This document provides post scenario documentation and guided reflection of Jennifer Holfman's case in VSIM Nursing.
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Medical Case 2: Jennifer Hoffman - Documentation Assignments1. Document your initial focused respiratory assessment of Jennifer Hoffman.
ER Dept, Bed 143B
06/01/2021 at 1230H
Patient is oriented x 3, however looked anxious. Verbalizes she is “not good '' when asked how she feels. Eyes are 5
mm and reactive to light. Shows signs of air hunger. She appears cyanotic. Skin feels cool to touch and diaphoretic.
Patient was constantly coughing. P: 105 bpm, regular, right. BP: 124/72 mmHg left sitting. RR: 31 bpm. SPO2: 72%
finger. A lot of wheezes bilaterally on auscultation. Use of accessory muscles noted.******************LD, SPN
2. Identify and document key nursing diagnoses for Jennifer Hoffman.
Impaired gas exchange related to bronchospasm and bronchoconstriction secondary to acute asthma attack as
evidenced by oxygen saturation of 72%, client wheezing and coughing, patient unable to speak more than one-
word sentences.
3. Referring to your feedback log, document the nursing care you provided.
ER Dept, Bed 143B
06/01/2021 at 1235H
Patient has no known allergy. Upon completing priority assessments, oxygen 10L via NRB was given. IV site has no
signs of infection, infiltration, or bleeding; infusing 150 mL/hr of normal saline. IV Dressing is dry and intact. All
scheduled medication administered as ordered; see MAR.***************************************LD, SPN
Vitals reassessed at 1245H: RR: 21 bpm, SPO2 99% finger, BP: 135/80 mmHg sitting left, P: 110 bpm regular. TPR:
37*C SL. A few wheezes bilaterally were noted upon auscultation. Chest is moving equally on both sides. Patient
verbalizes “I feel better” when asked how she feels. Patient education about medication was provided. Patient is
stable and will continue to monitor********************************************************LD, SPN
Medical Case 2: Jennifer Hoffman
Guided Reflection Questions
1.How did the scenario make you feel?
It was alarming initially because Jennifer looked visibly unwell, noting cyanosis. From there, the need of the
patient was recognized (Oxygen), therefore she was assessed based on priority, pertinent assessment and
intervened quickly. I believe this was highly important to note this in the scenario because the patient can decline
rapidly when an airway issue is present. Any need that affects airway, breathing and circulation is an emergency
and should be recognized, addressed promptly and acted upon by the priority need of the client to prevent the
patient from further danger.
2. What assessment findings would indicate that the patient’s condition is worsening?
● SPO2 <95%
● ABGs pH <7.35, PaCO2>45 mmHg, HCO3 >26mmol/L, PaO2 <80mmHg
● Lung sounds: wheezing (status asthmatic – stopped wheezing)
● RR: increased
● Hypotension
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