Jersonjabonete
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Documentation Assigment
Document your initial, focused assessment of Jackson Weber. On initial assessment of Jackson Weber, he was alert and oriented x 3, with his mother at his bedside. He rated his pain a 0 on a scale of 0–5 using the FACES scale, and when asked, he stated that he did not have any pain. RR was 14 breaths per minute, with the chest moving equally. BP 120/80, SpO2 98%, Temp 98F, Pulse 100 per minute Skin color was normal, and the patient was not sweating.
- Other
- • 2 pages •
Document your initial, focused assessment of Jackson Weber. On initial assessment of Jackson Weber, he was alert and oriented x 3, with his mother at his bedside. He rated his pain a 0 on a scale of 0–5 using the FACES scale, and when asked, he stated that he did not have any pain. RR was 14 breaths per minute, with the chest moving equally. BP 120/80, SpO2 98%, Temp 98F, Pulse 100 per minute Skin color was normal, and the patient was not sweating.
Guided Reflection
I knew to immediately put her in the Trendelenburg position during my initial assessment, then obtained the most accurate information and gave her a fundal massage, then phoned the provider. She received the appropriate medications and interventions at the right time.
- Other
- • 2 pages •
I knew to immediately put her in the Trendelenburg position during my initial assessment, then obtained the most accurate information and gave her a fundal massage, then phoned the provider. She received the appropriate medications and interventions at the right time.