Medical Case 1: Kenneth Bronson Vsim Assignments

Document Content and Description Below

Medical Case 1: Kenneth Bronson Documentation Assignments 1. Document Kenneth Bronson’s new allergy information in his patient record. Allergic to Ceftriaxone. Given 1g IV @ 1108, Pt c/o of t... hroat swelling, unable to breathe. Allergic to antibiotic class, cephalosporins. 2. Document your initial focused respiratory assessment of Kenneth Bronson. RR 17/min, reduced breath sounds at right lung base upon auscultation. SpO2 95% NC 2 L/min. Pt is a tobacco smoker, “2 packs a day for the past 10 years.” Pt c/o tiredness and chest tightness. 3. Document the assessment changes that occurred before and after the anaphylactic reaction. Before anaphylactic reaction, VS were stable: RR 18/min, SpO2 95% NC 2 L/min, BP 138/82 mm Hg, Temp 102 F, HR 100/min strong and regular. During/after anaphylactic reaction, VS: RR 36/min airway sounds obstructed, increased respiratory effort, SpO2 92% non-rebreather mask 10 L/min, BP 140/80 mm Hg, HR 144/min, urticarial rashes on chest 4. Identify and document key nursing diagnoses for Kenneth Bronson. Ineffective airway clearance Ineffective breathing pattern Impaired gas exchange Decreased Cardiac Output Infection 5. Referring to your feedback log, document the nursing care you provided. Feedback Log 4:49 You started infusing ceftriaxone. This is part of the correct treatment of this condition, and you typically infuse this over 30 minutes. It is important to use the basic rights of medication administration to ensure proper drug therapy.. 4:49 The patient started developing an allergic reaction to the antibiotic. 5:01 You stopped infusing ceftriaxone. Correct. It is very important to stop any infusions when an anaphylactic reaction has developed. 5:10 Patient status - ECG: Sinus tachycardia. Heart rate: 107. Pulse: Present. Blood pressure: 134/78 mm Hg. Respiration: 19. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C) 5:11 You phoned the provider in order to discuss the patient. 5:28 You gave the patient 100% oxygen from a non-rebreathing mask. This was part of your orders. 5:52 Patient status - ECG: Sinus tachycardia. Heart rate: 115. Pulse: Present. Blood pressure: 135/75 mm Hg. Respiration: 24. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C) 5:54 You attached a 3-lead ECG. It is correct to attach the monitor to the patient. 6:14 You administered 0.5 mg of epinephrine 1:1000 intramuscularly. 6:48 You flushed the cannula. 6:50 Patient status - ECG: Sinus tachycardia. Heart rate: 124. Pulse: Present. Blood pressure: 128/69 mm Hg. Respiration: 29. Conscious state: Appropriate. SpO2: 96%. Temp: 102 F (39.1 C) 6:56 A 50 mg dose of diphenhydramine was injected. It was reasonable to administer an antihistamine here. 7:30 You started infusing ranitidine. Correct. This was part of your orders. [Show More]

Last updated: 1 year ago

Preview 1 out of 6 pages