1. Document your initial focused respiratory assessment of Jennifer Hoffman.
2. Identify and document key nursing diagnoses for Jennifer Hoffman.
Referring to your feedback log, document the nursing care you provided.
Part #2 Guided Reflection Questions
1. Document your initial focused respiratory assessment of Jennifer Hoffman.
Jennifer Hoffman is a 33-year-old female brought to the Emergency Department, has a
history of asthma since childhood with multiple emergency visits within the last year. She
seems to be having breathing difficulties, she is only able to talk in brief, short phrases.
An infusion of normal saline has started at 25ml/hr. Patient is tachypneic 30 breaths per
minute with increased respiratory effort and audible wheezing, tachycardiac with 105
strong and regular pulse per minute, SpO2 73% indicates hypoxemia, Temperature 99F,
and Blood pressure 126/74mm of Hg.
2. Identify and document key nursing diagnoses for Jennifer Hoffman.
Ineffective breathing related to bronchospasm as evidenced by cough, tachypnea,
wheezing in the chest, and decreased SpO2.
3. Referring to your feedback log, document the nursing care you provided.
I introduced myself, washed my hands and verified the identity of the patient for patient
safety
I asked if the patient was allergic to anything.
I auscultate the lungs of the patient. There was a lot of audible wheezing in the chest.
I attached the pulse oximeter, assessed redial pulse, measured the blood pressure and
checked patient`s the temperature.
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