MEDICAL NURSING Documentation Assignments Hoffman

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Medical Case 2: Jennifer Hoffman
Documentation Assignments

1. Document your initial focused respiratory assessment of Jennifer Hoffman.
The initial focused respiratory assessment findings are the following: Sinus tachycardia.
Heart rate: 117. Pulse: Present. Blood pressure: 133/79 mm Hg. Respiration: 25. Conscious
state: Appropriate. SpO2: 78%. Temp: 99 F (37 C)

2. Identify and document key nursing diagnoses for Jennifer Hoffman.
Some nursing diagnoses for Jennifer Hoffman are: 1) Ineffective breathing pattern related to
asthma, 2) Anxiety related to asthma

3. Referring to your feedback log, document the nursing care you provided.
Some of the nursing care that I provided were as following:
 I introduced myself
 Washed my hands
 Identified the patient to maintain patient safety
 Ask if patient is allergy to anything and also if she is in pain
 I did vital signs including placing 3-lead ECG and nasal oxygen cannula
 I administer doctors order of albuterol, Ipratropium, methylprednisolone, and normal
saline IV




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