College aantekeningen
Vincent Brody VSIM
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This document provides post scenario documentation and guided reflection of Vincent Brody's case in VSIM Nursing.
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Medical Case 3: Vincent Brody - Documentation Assignments1. Document your focused respiratory assessment for Vincent Brody.
● Initial respiratory Assessments
○ dry cough was noted upon entering the room
○ RR is 21 bpm, and the chest is moving normally bilaterally
○ SPO2 is 93% finger
○ few edible wheezes was noted upon lung auscultation
○ ABG: patient has respiratory acidosis with full compensation
■ ABGs: HCO3- 26.3 (high, alkaline) , PCO2 49 (high, acidic), ph 7.40 (norm)
○ chest x-ray results in a very large simple pneumothorax present.
● Subsequent respiratory assessments when SOB and chest pain occurred ,
○ pain level of 2/10, occurs when patient takes a breath as stated
○ SPO2 is 88% at 12:39 and declining
○ RR is 34 bpm, chest is not moving very well
○ reduced breath sounds on left and normal breath sounds on the right
● Respiratory Assessment after Dr was notified and nsg interventions (O2 therapy, albuterol, morphine and chest tube insertion) .
○ x ray confirms placement is in good position; dressing clean, dry and intact
○ RR: 31 bpm and improving
○ a few audible wheezes. left side with reduced breath sounds and present of breath sounds on right upon auscultation
○ spo2 increasing (left at 91% at 12:48)
2. Identify and document key nursing diagnoses for Vincent Brody.
● Impaired breathing pattern r/t respiratory distress secondary to COPD as e/b by dyspnea, tachypnea, reduced breath sounds
on left side and few audible wheezes on auscultation, dry hacking cough.
● Risk for infection related to chest tube insertion
● Activity tolerance r/t imbalance o2 supply and demand as e/b dyspnea, SOB, rr way above norm, patient states “it (chest) hurts
when I breathe” .
3. Document (chest pain) pain management interventions and Vincent Brody’s response to therapy.
06/17/2021
Medical Unity, bed 123b at 12:45
Patient c/o of chest pain level 2/10. patient states “it hurts when I take a breath”. Notified provider as per relevant assessment
performed. Prior to chest tube insertion, 2 mg of morphine via slow IV push was given as per Doctor's new order Patient
tolerated the medication well. No respiratory distress noted.*******************************************SPN3, L.D
4. Document key assessments you would monitor for a chest tube (insertion site, dressing, suction level, drainage, fluctuation, air
leak).
○ Insertion site:
■ ensure that the chest tube is secured to the client’s chest wall and that connections are securely taped to avoid
disconnection.
■ Keep the collection devices below the client’s chest level.
■ Chest tube insertion and removal require sterile technique and must be done without introducing air or microorganisms
into the pleural cavity.
■ Dressing: inspect dressing for excessive/ abnormal drainage (bleeding, foul smell discharge) at least q4h.
■ Palpate around the dressing site for any ‘crackling’ sensation (feeling of touching Rice Krispies),
, Medical Case 3: Vincent Brody - Documentation Assignments
■ listen for a crackling sound indicative of subcutaneous emphysema (subcutaneous emphysema is air in the subcutaneous
tissues and can result from a poor seal at the chest tube insertion site. If subcutaneous emphysema is present, inform the
physician)
■ If the chest tube is inadvertently pulled out, the wound should be immediately covered with a dry sterile dressing
■ Remove the dressing around the tube, and prepare the dressing that will cover the insertion site.
○ Suction level:
■ Frequently check the water seal and suction control chambers.
○ Drainage
■ monitor patency and integrity of the drainage system
■ Keep the collection devices below the client’s chest level.
■ Assess the drainage in the tubing and collection chamber
■ The drainage is measured at regularly scheduled times (per agency policy).
■ Mark the date and time at the fluid level on the drainage chamber
■ If drainage suddenly increases or if there is more than 100 mL/h of blood drainage, inform the appropriate member of the
health care team.
■ When transporting and ambulating the client, disconnect the drainage system from the suction apparatus before moving
the client and make sure the air vent is open.
○ Fluctuation
■ The water seal level should fluctuate with respiratory effort.
○ Air leak
■ Avoid aggressive chest tube manipulation (e.g., milking or stripping the tube) to remove clots, as milking can create
excessive negative pressure that can harm the pleural membranes and/or surrounding tissues (Durai, Hoque, & Davies,
2010).
■ If the tube becomes disconnected from the collecting system, submerge the end in 2.5 cm of sterile saline or water to
maintain the seal.
■ If you can hear air leaking out the site, ensure that the dressing is not occlusive (Kozier et al.,2018, p. 1315 - 1317 )
5. Referring to your feedback log, document the nursing care you provided.
06/17/2021, at 12:30
Medical Unity, bed 123b
● Patient was found in supine position, with a dry hacking cough,
● introduce self, performed hand hygiene, check two identifiers, check allergy and obtain consent prior to care, position
patient to semi fowlers
● VS and assessed IV access (attached 3-lead ECG, BNP, Pulse ox)
● checked orientation x3
● auscultated heart and lungs
● At 12:40, patient experiences dyspnea & chest pain: Pain was assessed and noted VS + heart sounds (esp RR, SPO2 and
lung breath sounds). Gave pt 10L of O2 via NRBM. Administered albuterol. Obtained ABGs. Following, the Doctor was
notified. Then performed new Doctor’s orders such as: obtaining chest x ray; chest tube insertion was requested. (
Obtained consent) and gave 2 mg of morphine via IV flush as per Doctor’s order prior to procedure.
● Obtained consent and chest tube was performed by MD.
● Follow ups: chest tube placement via chest x ray, dressing site. VS +pain, IV site, lung and heart auscultation, orientation x3.
● patient left in semi fowler’s position, maintained SPO2 of greater than 90%, no pain, educated patient about chest tube,
dyspnea & pain. call the bell within reach.
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