Class notes
Vernon Watkins VSIM
- Course
- PNUR205
This document provides post scenario documentation and guided reflection of Vernon Watkins's case in VSIM Nursing.
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Surgical Case 4: Vernon Watkins - Documentation Assignments1. Document Vernon Watkins’ respiratory assessment that occurred in the case.
● RR: is 24 bpm, SPO2 is 92% at RA and declining, patient c/o difficulty breathing, patient verbalizes “it hurts when i
breathe”
● patient’s chest moves equal bilaterally
● Mr. Watkin’s lung sounds is normal
● upon administering heparin and o2 therapy, patient’s SPO2 improved and left at 94% via NRBM
2. Document the actions during the acute respiratory distress episode.
● The patient was given 6L of O2 via NC initially at 0910h.
● When there was no signs of improvement on the patient’s breathing till 09:20 to maintain a level of >92% SPO2,
therefore, the patient's o2 delivery was shifted to NRBM at 10L. Signs of improvement were noted.
3. Document the changes in Vernon Watkins’ vital signs throughout the scenario.
initial before medical procedures (Chest x-ray etc.) After O2 therapy and heparin admin.
T 37*C oral T 37*C oral T 37*C oral
P 112 finger P 111 finger P 107 finger -
R 24 bpm R 24 bpm R 24 bpm
BP 151/90 , LA, sitting BP 149/90, LA, sitting BP 151/91, LA, sitting
SPO2 92% RA and declining SPO2 92% via NC SPO2 94% via NRBM at 10L
4. Identify and document key nursing diagnoses for Vernon Watkins.
● Altered Tissue Perfusion
● Ineffective breathing pattern, Impaired Gas Exchange
● Pain
● Anxiety
● Risk for injury
● Impaired mobility
● Risk for bleeding
5. Referring to your feedback log, document the nursing care you provided.
● Patient was found in supine position
● introduce self, performed hand hygiene, check two identifiers, check allergy and obtain consent prior to care,
● position patient to semi fowlers
● assessed how the patient is feeling
● At 09:05, VS + pain and assessed IV access ,dressing on ABD and attached automatic NIBP, Pulse ox, ECG monitoring),
checked orientation x3, assessed skin
● auscultated heart and lungs and ABD
● provided patient 2L of O2 via NC
● At 09:11, called HCP and new orders were provided
○ pertinent VS were reassessed. Following, spiral ct, ecg monitoring 12 led, chest x ray, venous blood sample, ABG
sample were performed
● Administered heparin + heparin in D5W via IV as per Doctor's order
● At 09:20, VS reassessed, changed NC to NRBM of 10L, patient education was provided about the situation that had
occurred, informing and relieving the patient that he’s going to be continually monitored until stable, notifying iif the
patient has any questions
● Left patient at lying position with SPO2 of 94%, call bell within reach.
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