Need ADSAP please!INSTRUCTIONS on the bottom! Please fill this out for oxygenation! Scenario:

Question Answered step-by-step Need ADSAP please!INSTRUCTIONS on the bottom! Please fill this out for oxygenation! Scenario: 48 year old Hispanic female: Presented to ER with C/O Chest pain, Alcohol intoxification, generalized body tremors.PMH: Smoker x25 years , ETOH abuse, Hypertension, Diabetes, Bipolar disorder, Depressive disorder, chronic constipation, Pancreatitis ,Cirrhosis  of the liver and  right side heart failure. PSH:    Fibroid Removal – eight years ago.  Allergies: PERCOCET /Penicillin Advance Directives:Living Will: yes   no   x    FULL CODE- yesPhysical Assessment Data:B/P 172 /114 HR 130 BPM   RR 36    T 100.1   Wt.   102    lbs   Ht. 5.5Pain scale (0-10) 5 Pain Assessment: Numeric pain scale.Description of Patient’s Mood / Behavior: Fatigue, weakness, reactive to all stimuli (noise, light, touch, ) periods of confusion, suspicious, apprehensive.Statement of General Appearance:Multiple bruises all over body in different stages of healing. Malodorous, hair unkempt. Visible generalized tremors observe. Toenails and finger nails discolored (dirt present under nail beds.   OXYGENATION:  Respiratory rhythm:  irregular: 36  oxygen saturation 89% Breath sounds: IRREGULAR Adventitious sounds: crackles: NO, rhonchi:  NO, wheezing: NO Use of Oxygen: nasal cannula: NO, mask: YES, trach collar: NO Oxygen therapy:  NON REBREATHER MASK Comments: PATIENT WOULD NOT ALLOW NASAL CANNULA, ATTEMPT SEVERAL TIMES TO REMOVE NON REBREATHER MASK Please fill this out for oxygenation! Nursing diagnoses:Interventions/Management:Outcomes/Goals:Interdisciplinary groups:Patient education:  Health Science Science Nursing NURS 22000 Share QuestionEmailCopy link Comments (0)