Surgical Case 4: Vernon Watkins Documentation Assignments 1. Document Vernon Watkins’ respiratory assessment that occurred in the case. Pt. breathing with equal chest rise and fall, lung sounds clear and equal bilateral. Pt RR 24 Pt is speaking in full sentences however, Pt appears anxious with increased work of breathing. SP02 read 90% on room air. Pt states that it is painful to breath Pt rates pain at 3 out of 10 on the pain scale. 2. Document the actions during the acute respiratory distress episode. Upon completing Pt respiratory assessment Pt was assisted to the sitting position to better Pt breathing. 02 was started 15lpm via non rebreather mask, and the provider was advised of the change in the patient’s condition. The provider ordered a 12 lead EKG, chest Xray, Spiral CT of Pt chest, ABG, venous blood sample. 6400 units of heparin were given IV bolus and a maintenance drip o ...
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