Medical Case 3: Vincent Brody Documentation Assignments
Document your focused respiratory assessment for Vincent Brody.
Identify and document key nursing diagnoses for Vincent Brody.
Document pain management interventions and Vincent Brody’s response to therapy.
Document key assessments you would monitor for a chest tube (insertion site).
Please type, I cannot see and read the handwriting.
The Correct Answer and Explanation is:
1. Focused Respiratory Assessment for Vincent Brody:
Assessment Findings:
- Respiratory Rate: 28 breaths/min, labored
- Oxygen Saturation: 89% on room air; 94% with 2L nasal cannula
- Breath Sounds: Diminished in left lower lobe, crackles in right mid-lobe
- Chest Expansion: Asymmetrical; decreased movement on the left side
- Cough: Non-productive, weak effort
- Use of Accessory Muscles: Present
- Skin Color: Pale with slight cyanosis around lips
2. Key Nursing Diagnoses:
- Impaired Gas Exchange related to alveolar-capillary membrane changes as evidenced by low SpO₂ and abnormal breath sounds.
- Ineffective Breathing Pattern related to pain and fatigue as evidenced by labored breathing and use of accessory muscles.
- Acute Pain related to chest tube insertion as evidenced by verbalization of pain and guarded movement.
3. Pain Management Interventions and Response:
Interventions:
- Administered prescribed IV morphine 2 mg q4h PRN
- Applied cold pack to insertion site for 15 minutes
- Encouraged use of incentive spirometer to manage discomfort while improving lung expansion
Patient Response:
- Verbalized pain decreased from 7/10 to 3/10 within 30 minutes post-medication
- Appeared more relaxed, able to take deeper breaths
- Participated in breathing exercises with minimal distress
4. Chest Tube Assessment:
Key Assessments:
- Insertion Site: Clean, dry, intact with occlusive dressing
- Drainage System: Water seal chamber at appropriate level, tidaling present, no continuous bubbling
- Drainage: Serosanguinous, 50 mL over past 8 hours
- Tubing: No kinks or dependent loops, securely taped
- Patient: Reports discomfort but no signs of respiratory distress or subcutaneous emphysema
Explanation
This documentation focuses on Vincent Brody’s respiratory status following the insertion of a chest tube, likely due to conditions such as pneumothorax or pleural effusion. A focused respiratory assessment includes observing for signs of respiratory distress, evaluating breath sounds, respiratory rate, SpO₂, and inspecting for use of accessory muscles and chest symmetry. These data points help determine the effectiveness of oxygenation and ventilation.
Nursing diagnoses are derived from objective and subjective data. “Impaired gas exchange” and “ineffective breathing pattern” are critical due to compromised pulmonary function. Pain from the chest tube insertion contributes to shallow breathing, increasing the risk of complications like atelectasis or pneumonia. Pain management is essential for promoting effective coughing, deep breathing, and mobility. Administering analgesics and non-pharmacological measures (e.g., cold therapy) can enhance comfort and lung function.
Chest tube assessment is crucial to detect complications such as infection, blockage, or pneumothorax recurrence. The insertion site must remain clean and sealed to prevent air leaks. Monitoring drainage type and amount helps identify abnormal bleeding or infection. Ensuring proper function of the drainage system—including the presence of tidaling and absence of bubbling—indicates patency and proper suction.
Thorough, accurate documentation ensures continuity of care and early identification of complications. It also informs the healthcare team of the patient’s progress and response to interventions, allowing for timely adjustments to the care plan.
