Melanie Holder
Medical Case 2: Jennifer Hoffman
Documentation Assignments
1. Document your initial focused respiratory assessment of Jennifer Hoffman.
2. Identify and document key nursing diagnoses for Jennifer Hoffman.
3. . Document your phone call to the provider, including the information you provided
regarding the significant changes in Jennifer Hoffman
4. Referring to your feedback log, document the nursing care you provided.
1) Document your initial focused respiratory assessment of Jennifer Hoffman
Pt. appears to be in respiratory distress, struggling to breathe or communicate with one-word
statements. Her RR is 29 breaths per min with increased respiratory effort; she uses the
accessory muscles. There are audible wheezes in the chest; Sp02 78%, and non-productive
cough.
2. Identify and document key nursing diagnoses for Jennifer Hoffman.
a) Ineffective breathing pattern r/t swelling and spasm of the bronchial tubes AEB cough,
tachypnea, use of accessory muscles, wheezing, decreased SpO2.
b) Ineffective airway clearance r/t bronchospasms increased pulmonary secretions, and
ineffective cough AEB adventitious lung sounds (wheezes, rhonchi).
c) Anxiety r/t respiratory distress AEB dyspnea and restlessness
d) Activity intolerance r/t airway problem AEB prolonged dyspnea d/t an asthma attack, lethargy
e) Deficient knowledge r/t chronicity of diseases, lack of information sources AEB inability to
identify triggers, ineffective self-care, absence of adequate medication for condition.
3) Jennifer Hoffman is a 33-year-old female, with a history of asthma. I took her vitals and
attached a nasal canula to run at 1Fi/4L per min per dose as ordered. I have administered
4mL via nebulizer of Ipratropium/Formoterol as per orders. She was also given 125mg of
methylprednisolone as per orders. I then attached a noninvasive blood pressure cuff to
reassess her blood pressure continuously her capillary refill time was 2 seconds, and she is
alert and oriented times four. I have warmed and humified her oxygen to help her breathing.
© Wolters Kluwer Health | Lippincott Williams & Wilkins
This study source was downloaded by 100000866593027 from CourseHero.com on 05-22-2025 22:33:36 GMT -05:00
https://www.coursehero.com/file/198046238/Nursing-Case-Study-Jennifer-Hoffmans-Respiratory-Assessment/
, She is still experiencing shortness of breath, wheezing, coughing and can only reply in short
sentences.
4). Referring to your feedback log, document the nursing care you provided.
Assessed VS and IV patency; monitored SpO2 and maintained oxygen level >92% through non-
rebreather mask and NC; monitored ECG; assessed respirations and breaths sounds;
examined chest and heart; auscultated lungs and heart; changed bed position; meds
administration (short-acting beta2-adrenergic agonists, anticholinergics, and
corticosteroids); provided education.
Guided Question
Opening Questions
How did the scenario make you feel?
Scenario Analysis Questions
PCC What assessment findings would indicate that the patient’s condition is worsening?
PCC When a patient develops a rapid onset of shortness of breath, what are the nurse’s
immediate priorities?
PCC/I Review Jennifer Hoffman’s laboratory results. Identify which results are abnormal and
discuss how this relates to her clinical presentation and the disease process.
Concluding Questions
© Wolters Kluwer Health | Lippincott Williams & Wilkins
This study source was downloaded by 100000866593027 from CourseHero.com on 05-22-2025 22:33:36 GMT -05:00
https://www.coursehero.com/file/198046238/Nursing-Case-Study-Jennifer-Hoffmans-Respiratory-Assessment/
Medical Case 2: Jennifer Hoffman
Documentation Assignments
1. Document your initial focused respiratory assessment of Jennifer Hoffman.
2. Identify and document key nursing diagnoses for Jennifer Hoffman.
3. . Document your phone call to the provider, including the information you provided
regarding the significant changes in Jennifer Hoffman
4. Referring to your feedback log, document the nursing care you provided.
1) Document your initial focused respiratory assessment of Jennifer Hoffman
Pt. appears to be in respiratory distress, struggling to breathe or communicate with one-word
statements. Her RR is 29 breaths per min with increased respiratory effort; she uses the
accessory muscles. There are audible wheezes in the chest; Sp02 78%, and non-productive
cough.
2. Identify and document key nursing diagnoses for Jennifer Hoffman.
a) Ineffective breathing pattern r/t swelling and spasm of the bronchial tubes AEB cough,
tachypnea, use of accessory muscles, wheezing, decreased SpO2.
b) Ineffective airway clearance r/t bronchospasms increased pulmonary secretions, and
ineffective cough AEB adventitious lung sounds (wheezes, rhonchi).
c) Anxiety r/t respiratory distress AEB dyspnea and restlessness
d) Activity intolerance r/t airway problem AEB prolonged dyspnea d/t an asthma attack, lethargy
e) Deficient knowledge r/t chronicity of diseases, lack of information sources AEB inability to
identify triggers, ineffective self-care, absence of adequate medication for condition.
3) Jennifer Hoffman is a 33-year-old female, with a history of asthma. I took her vitals and
attached a nasal canula to run at 1Fi/4L per min per dose as ordered. I have administered
4mL via nebulizer of Ipratropium/Formoterol as per orders. She was also given 125mg of
methylprednisolone as per orders. I then attached a noninvasive blood pressure cuff to
reassess her blood pressure continuously her capillary refill time was 2 seconds, and she is
alert and oriented times four. I have warmed and humified her oxygen to help her breathing.
© Wolters Kluwer Health | Lippincott Williams & Wilkins
This study source was downloaded by 100000866593027 from CourseHero.com on 05-22-2025 22:33:36 GMT -05:00
https://www.coursehero.com/file/198046238/Nursing-Case-Study-Jennifer-Hoffmans-Respiratory-Assessment/
, She is still experiencing shortness of breath, wheezing, coughing and can only reply in short
sentences.
4). Referring to your feedback log, document the nursing care you provided.
Assessed VS and IV patency; monitored SpO2 and maintained oxygen level >92% through non-
rebreather mask and NC; monitored ECG; assessed respirations and breaths sounds;
examined chest and heart; auscultated lungs and heart; changed bed position; meds
administration (short-acting beta2-adrenergic agonists, anticholinergics, and
corticosteroids); provided education.
Guided Question
Opening Questions
How did the scenario make you feel?
Scenario Analysis Questions
PCC What assessment findings would indicate that the patient’s condition is worsening?
PCC When a patient develops a rapid onset of shortness of breath, what are the nurse’s
immediate priorities?
PCC/I Review Jennifer Hoffman’s laboratory results. Identify which results are abnormal and
discuss how this relates to her clinical presentation and the disease process.
Concluding Questions
© Wolters Kluwer Health | Lippincott Williams & Wilkins
This study source was downloaded by 100000866593027 from CourseHero.com on 05-22-2025 22:33:36 GMT -05:00
https://www.coursehero.com/file/198046238/Nursing-Case-Study-Jennifer-Hoffmans-Respiratory-Assessment/
