Reference no: EM133993745

Patient Introduction

Location: Medical Unit 1600

Report from day shift nurse:

Situation: Mrs. Hernandez is a 72-year-old Hispanic female who was admitted to the medical unit yesterday afternoon with a diagnosis of pneumonia in her right lobe. Chest X-ray shows infiltrates in right lower lobe, indicative of pneumonia. She was started on antibiotics after a sputum specimen for Gram stain culture was obtained. We are monitoring her respiratory status closely.

Background: Mrs. Hernandez was experiencing symptoms of dry cough, fever, and malaise, and was diagnosed with influenza 10 days prior to admission. Her symptoms got progressively worse, and yesterday she had a temperature of 38.4 °C (101.2 °F), shaking, chills, and a productive cough of rust-colored sputum. Her primary care provider saw her yesterday and decided to admit her for treatment of pneumonia.

Assessment: Mrs. Hernandez is alert and oriented ×3, but appears tired. She reports sharp chest pain with coughing and shortness of breath with activity. She rated the pain as a 6 on a scale of 0-10 and was given acetaminophen 650 mg at 1400. Vitals signs were taken at 1200. Her temperature has been elevated since this morning and was 38.1 °C (100.6 °F). Pulse is 104/min, respirations 24/min, and blood pressure 112/72 mm Hg. Her saturation was 95% on nasal cannula with oxygen at 3 L/min. Her respirations were labored when she came back from the bathroom, but improved when she settled back in bed.

Recommendation: You should make sure to maintain saturation levels above 94%. Mrs. Hernandez needs encouragement to cough and deep breathe, and to use incentive spirometry. She only uses her incentive spirometer after much encouragement. You should also start patient education on disease process and management.

Mona Hernandez

Documentation Assignments

1. Document your focused assessment of Mona Hernandez.

2. Document your assessment findings and any nursing interventions related to Mona Hernandez's oxygenation after ambulation.

3. Document your education to Mona Hernandez regarding the purpose of, and how to use, the incentive spirometer.

4. Referring to your feedback log, document the nursing care you provided to Mona Hernandez and her response.