Question

Oxygenation Scenario Student Documentation Oxygenation Scenario Documentation. Ms. Jones, a 70 year old, Caucasian female was admitted to the Medical-Surgical floor for Pneumonia today. She is AAOX3. PERRLA, wears glasses. Denies hearing difficulties. Trachea midline, denies difficulty swallowing. States poor appetite "past two davs" Chest symmetrical, Respirations 22 Breathing labored. C/O, Shortness of Breath which increases with exertion. Denies smoking breath sound course; productive cough of tenacious, thick strong bilaterally. BP 138/80, heart rate @ 86 regulac rate and rhythm, denies chest pain, Abd. Round soft, non-distended. BS+x4 quads. Denies abd. Pain. States last BM, 2 days ago, normal pattern and consistency. Voids to BSC; noted approximately 100 cc dark amber urine; denies burning, itching with urination. Moves all 4 extremities well. Capillary refill brisk in nailbeds. IV NS infusing int 125 ml/Hr; there is no redness, swelling, draining or c/o pain at IV site. Flexes and without difficulty. Lower extremities strong against resistance. Pedal pulses +. No skin break noted on the backside. Instructed not to get OOB witho Document what you do for this patient now. Include all interventions. present in napkin, Hand Grips or pain o RFA@ Dorsi-fl exes feet ut assistance. SR up x2, call light within reach. It has been two days Ms. Jones is doing well. She had a chest x-ray this a.m. and she has pleural effusions and fluid in the lower lung lobes. X-rays sent to the MD and you have received a new order for Chest Tube setup and assist. The order reads: Chest Tube Setup-Aqua Seal with 20cm. of suction. Trocar fr 30. and surgical tray at bedside. Document setup and assist for Ms. Jones; include any teaching necessary

Answer 1

1. Interventions based on the sign and symptoms are :-

- Oxygen administration

- Semi Fowler's position

- Provision of comfort and rest to the patient

- Nebulization to remove the secretions

- IV antibiotics for pneumonia and infection

- IV fluid therapy

- drink plenty of fluids

- Chest X- ray to detect pleural effusion

- if pleural effusion is present then thoracentesis has to be done .

2. Setup for chest tube insertion include :-

- surgical tray with chest tube insertion equipment like blade , sutures ,chest tube with water seal chamber ,bandage ,sterile gauze etc

- aqua seal with 20 cm of suction

- trocar fr. 30

Teaching to the patient include :-

- teach and advice deep breathing exercises

- teach how to do incentive spirometry

- advice patient to maintain semi Fowler's position

- after insertion of tube lie to the tube inserted side for easy drainage for 2to 3 hours .

- advice to monitor the fluctuations, excessive air bubbles etc in the water seal chamber

- drink plenty of fluids

- advice to monitor the insertion sign for signs of I Fe room like redness , inflammation ,pus discharge etc and inform it to the physician and any dislodge of tubing's .