Clinical Replacement mona PDF

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vSim ISBAR Activity

Student Worksheet

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

Situation Patient’s name, age, specific reason for visit

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

Mona Hernandez , 72 years of age, she has sharp chest pain with coughing and shortness of breath with activity.

Date of admission was January 23, 2021, Mrs. Hernandez was experiencing symptoms of dry cough, fever, and malaise, and was diagnosed with influenza 10 days prior to admission. Her symptoms got progressively worse, and yesterday she had a temperature of 38.4 °C (101.2 °F), shaking, chills, and a productive cough of rust-colored sputum. Her primary care provider saw her yesterday and decided to admit her for treatment of pneumonia. Her primary diagnosis is pneumonia on her right lobe , x ray shows infiltrates in right lower lobe indicating pneumonia, she was started on antibiotics after a sputum specimen for Gram stain culture was obtained and monitoring respiration closely. Orders: vital sign every 4 hours Titrate oxygen to maintain saturation at 95 Flush saline lock every 8hrs and prn Diet regular encourage fluid intake Incentive spirometer Cbc with differential

Ambulate 3x a day Sputum specimen for gram stain Medication: acetaminophen 650mg 6hrs prn pain guaifenesin 100mg/5ml orally every 4 hrs prn cough hydrochlorothiazide 25 mg oral daily moxiflacin 400 mg iv piggy back daily 2200 heparin 5000 units subcutaneously twice daily at 0800 and 2000

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

Mrs. Hernandez is alert and oriented ×3, but appears tired. She reports sharp chest pain with coughing and shortness of breath with activity. She rated the pain as a 6 on a scale of 0–10 and was given acetaminophen 650 mg at 1400. Vital signs : Heart rate 119, pulse present, BP 144/87, Respiration, 22, SpO2 87%, temp 101 F.

Recommendation Any orders or recommendations you may have for this patient Use of incentive spirometer , deep breaths and coughing.

Patient Education Worksheet Name of medication, classification

Medication: acetaminophen, guaifenesin, hydrochlorothiazide, moxifloxacin, heparin

Classification: Acetaminophen-non opioid analgesic and antipyretic Guaifenesin-expectorant Hydrochlorothiazide-antihypertensive Moxifloxacin-fluoroquinolone antibiotic Heparin-anticoagulant

Safe dose or dose range, safe route acetaminophen -650mg 6hrs prn pain guaifenesin- 100mg/5ml orally every 4 hrs prn cough hydrochlorothiazide- 25 mg oral daily moxifloxacin- 400 mg iv piggy back daily 2200 heparin- 5000 units subcutaneously twice daily at 0800 and 2000

Purpose of this medication

Acetaminophen- for treatment of pain, mild fever Guaifenesin- helps loosen congestion in your chest and throat, making it easier to cough out through your mouth Hydrochlorothiazide- helps your body get rid of extra salt and water. This medication also reduces extra fluid in the body edema. Moxifloxacin- to treat infections like pneumonia Heparin- is an anticoagulant (blood thinner) that prevents the formation of blood clots.

Patient education while taking this medication Acetaminophen- only for mild pain Guaifenesin- patient to cough and sit upright and take several deep breaths before coughing Hydrochlorothiazide- advise patient report rash, muscle weakness, cramps, nausea, vomiting, diarrhea or dizziness to provider Moxifloxacin- can cause dizziness and drowsiness. Patient t needs to notify provider in case of diarrhea, rash and signs of hypersensitivity develop. Heparin- advise patient to report symptoms of unusual bleeding and bruising to provider immediately. And inform medication regimen before treatment.

Concept Map Worksheet Describe disease process affecting patient (include pathophysiology of disease process)

Pneumonia is an infection of the lungs that is caused by bacteria, viruses or fungi. It makes the alveoli become inflamed and get filled with fluid or pus making the oxygen harder to get in blood stream resulting in shortness of breath, chest pain, difficulty breathing, etc. types of pneumonia community acquired, hospital acquired, health care associated pneumonia, ventilation acquired pneumonia.

Diagnostic test (reason for test and results) X ray of thorax: shows right lower lobe pneumonia Arterial blood gases: pH: 7.3 HCO3- 22 Base excess- -1 PCO2-58 PO2-72 SaO2-94 Blood analysis Hb-12.1 HCT-37 Platelets-351 WBC-18 RBC-4.2 Electrolytes K+ -4.1 Na+ -140 Creatinine – 0.76 Cl- 107 Urea nitrogen-10

Patient information Mona Hernandez 72 y/0 Female Hispanic Catholic

Anticipated physical findings cough, colored mucus and sputum, malaise, tachycardia, fever, high respiratory rate, low oxygen saturation level, high temperature, low blood pressure, chills, confusion, crackles

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Anticipated nursing interventions  Ambulate 3 times a day,  Encourage coughing and taking deep breathes  Encourage the use of the incentive spirometer  Monitor sputum  Vital signs every 4 hours Administer oxygen nasal cannula 3L/min to maintain sPO4 at 95  Administer medications prescribed  Encourage fluid and food intake  Educate on smoking cessation  Influenza and pneumonia vaccine recommendation  Educate patient on pneumonia  Evaluate pain level  Auscultate lungs  Asses respiratory rate  Raise patient to high sitting position...