Class notes
Doris Bowman VSIM
- Course
- PNUR205
This document provides post scenario documentation and guided reflection of Doris Bowman's case in VSIM Nursing.
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Surgical Case 3: Doris Bowman - Documentation Assignments1. Document Doris Bowman’s vital signs that occurred in the case.
PACU, Bed 123B
06/03/2021 at 1000h
Patient has NKA. oriented x3. patient c/o stomach pain level of 6/10, radiating around the stomach. Nothing
makes it worse or better. VS: RR 21 bpm, chest moving normal bilaterally, SPO2 95% finger, P 105 bpm regular
radial, TPR: 37*C oral, BP 152/92 mmHg left sitting. normal breath & heart sounds upon auscultation;
hypoactive upon ABD auscultation. no nausea. Noted normal skin turgor, cool, and diaphoretic. ABD surgical
site has 4x4 dry intact, clean gauze dressing with no drainage. Urine output via Foley catheter is 200 mL and
clear. IV site has no signs of infection, infiltration, bleeding and infusing at 125 mL/hr KCl in 5% dextrose & N/S
*********LD, SPN3
2. Document the actions that should be taken when Doris Bowman’s severe respiratory depression
occurs.
06/03/2021 at 1000h: Patient reports pain level of 6/10. Flushed IV. Administered morphine as per doctor’s
order of 2 mg IV push for pain >4 prn. Flushed IV. The patient was found semi conscious then became
unconscious when checked for responsiveness. Pupils are 1mm and not reactive to light and accommodation.
Deteriorating SPO2 noted. RR is 3 bpm, chest is not moving normally . Gave 10L of O2 via NC. Ventilate patient
10/min via ambu bag. Administered naloxone as per doctor’s order; see MAR. Notified Primary Doctor and will
continue to monitor ***************************************************************LD, SPN3
At 10:15h: Reassessed patient. Patient appears oriented x3. Pupil is 6 mm and reacts to light. Appears to be
coughing and groaning. VS are SPO2 98% finger, RR 21 bpm & chest is moving equal bilaterally, lung sounds
norm upon auscultation, P 95 strong regular carotid, Heart sound norm, BP 130/73 supine left. Patient is
stable. Notified doctor and will continue to monitor. *************************************LD, SPN3
3. Document the airway management that occurred during the scenario.
● Patient was given 10L of O2 via NC
● Patient was ventilated 10/min ambu bag
4. Identify and document key nursing diagnoses for Doris Bowman.
Acute pain related to post surgery secondary to abdominal hysterectomy as evidenced by the patient
verbalizing radiating pain around the stomach, “pain started after surgery” , pain lvl 6/10, increased pulse.
Event: Ineffective breathing pattern related to medication administration of morphine as evidenced by visible
respiratory distress based from respiratory assessment and altered LOC.
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