성인간호학 / V-sim / Vincent Brody / 5번 6번 / 디브리핑 보고서

소개

성인간호학 실습
V-sim
Vincent Brody / 5번 6번 / 디브리핑 보고서 입니다.

목차

I. Documentation Assignments
1. Document your focused respiratory assessment for Vincent Brody.
2. Identify and document key nursing priorities for Vincent Brody.
3. Document pain management interventions and Vincent Brody’s response to therapy.
4. Document key assessments you would undertake for a chest tube (insertion site, dressing, suction level, drainage, fluctuation, air leak).
5. Referring to your feedback log, document the nursing care you provided.

II. Guideline Reflection Questions
1. How did the scenario make you feel?
2. When a patient develops a rapid onset of shortness of breath, what are the nurse’s immediate priorities?
3. What assessment findings would indicate that the patient’s condition is worsening?
4. Review Vincent Brody’s laboratory results. Which results are abnormal? Discuss how these results relate to his clinical presentation and chronic disease process.
5. What are safety considerations when caring for a patient with a chest drain?
6. What key elements would you include in the handover report for this patient? Consider the ISBAR (introduction, situation, background, assessment, recommendation) format.
7. What patient teaching priorities would be important in the patient experiencing an acute exacerbation of COPD?
8. For a patient with COPD who is stable, what resources would you recommend?
9. What would you do differently if you were to repeat this scenario? How would your patient care change?

본문내용

1. Document your focused respiratory assessment for Vincent Brody.

대상자는 3년전에 폐기종 진단을 받았고, COPD 악화로 입원하였다.
대상자에게 호흡에 어려움이 있는지 사정 → ‘Yes’
대상자의 흡연 여부 사정 → 50년동안 하루에 2갑씩 담배를 피우고 있다.
ECG:동성 빈맥 - BP:126/75mmHg – HR:104회/min – RR:21회/min - T:37℃ – SpO2 93%
대상자 폐음 청진 : 가슴에서 약간의 쌕쌕거리는 소리가 들린다.
왼쪽 기흉 발생
chest X-ray : 왼쪽에 매우 큰 단순 기흉이 있다.
울혈성 심부전 징후는 없으며, 종격동은 정상이다.
ECG:동성 빈맥 - BP:140/83mmHg – HR:125회/min – RR:36회/min - T:37℃ – SpO2 85%

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