Charlie Snow Care Plan - Clinical Care Plan PDF

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Summary

Clinical Care Plan...

Description

CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT

Anaphylaxis is an acute allergic reaction to a substance that the body has become hypersensitive to. When it occurs your body releases chemicles into your body that produces an inflammatory response and can place the individual into shock due to sudden drop in blood pressure while also producing swelling of the airway.

(INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)

Anaphylaxis is generally diagnosed clinically through examination of symptoms in association with assessment of patients activities leading up to the onset of symptoms. To confirm anyphylaxis a blood test for tryptase and histamine can be ordered.

Charlie Snow is a 6yo male brought to the ED by his aunt. He presents with an audible wheeze, difficulty breathing and an SpO2 of 90%.Patient denies pain at this time. Aunt stated patient has a peanut allergy and had been eating a new brand of cookie.

DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) PATIENT INFORMATION

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Sudden onset low blood pressure Swelling of the face, neck and throat Difficulty breathing Tachycardia Weak pulse Uticaria Nausea and vomiting Wheezing Low SpO2

ANTICIPATED PHYSICAL FINDINGS

ANTICIPATED NURSING INTERVENTIONS -

-Place patient in a position of comfort to facilitate breathing Assess patient for past medical conditions and allergies. Administer oxygen to patient to maintain SpO2 over 94% Preform complete respiratory assessment with focus on airway patency Monitoring blood pressure and perfusion and support with fluids and medication Administration of epinepherine to reverse the anaphylaxis Administration of steroids and antihistamines to reduce the inflammation and triggering histamines Monitor patients vitals Educate patient of illness, procedures, medications and disease prevention.

vSim ISBAR ACTIVITY INTRODUCTION

STUDENT WORKSHEET My name is NURSEand I am the nurse assigned to your patient today in the emergency room.

Your name, position (RN), unit you are working on

SITUATION

Charlie Snow is a 6yo male child brought to the ED at 1500 for sudden onset dyspnea.

Patient’s name, age, specific reason for visit

BACKGROUND Patient’s primary diagnosis, date of admission, current orders for patient

ASSESSMENT Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs

RECOMMENDATION Any orders or recommendations you may have for this patient

He presented with an onset of severe dyspnea 30 minutes ago by his aunt that states he has a peanut allergy and the symptoms began shortly after he had eaten a new brand of cookie. Currently he is on orders for supportive oxygen via nasal canual or non-rebreather mask to maintain SpO2 >94%.

On assessment patients pain rated 0 on FACES. Patient stated he could not breath and felt like his throat was swelling. Patients SpO2 was 90%. His breath sounds were equal with stridor and prolonged expiration. Patients airway appears clear with no visible obstruction. Patients vitals are BP 86/54, 99*F, SpO2 90%, HR 145

I would like to continue with the oxygen as ordered on non-rebreather. I would recommend starting medications for treatment of anaphylaxis including epinephrine, an antihistamine, a steroid and also an infusion of IV fluids to bring his blood pressure up and maintain perfussion

PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE

MEDICATION: Methylprednisone 10mg IV

CLASSIFICATION: Corticosteroid, anti-inflamatory agent

PROTOTYPE: Cortisone

SAFE DOSE OR DOSE RANGE, SAFE ROUTE IV: children...