Kenneth Bronson v Sim #1 PDF

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Kenneth Bronson vsim...

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Medical Case 1: Kenneth Bronson Documentation Assignments 1. Document Kenneth Bronson’s new allergy information in his patient record. Patient allergies: Ceftriaxone. Pt. given IV infusion of 1g ceftriaxone. Pt. reported swelling of the throat and difficulty breathing after medication was administered. Infusion was stopped immediately. 2. Document your initial focused respiratory assessment of Kenneth Bronson. Low O2 saturation. Reduced lung sounds to rt lung base. Respirations of 17 breaths per minute. Patient is a 2 pack per day smoker. 3. Document the assessment changes that occurred before and after the anaphylactic reaction. Before reaction VS assessments were every 4 hours. After the reaction they were continuous. 4. Identify and document key nursing diagnoses for Kenneth Bronson. Impaired gas exchange related to increased respirations, decreased SpO2 levels, Increased heart rate and the coughing. 5. Referring to your feedback log, document the nursing care you provided. Introduced myself, washed my hands. Identified patient. Asked about allergies and how they were feeling. Difficulty breathing? Assessed VS. Assessed IV site. Washed hands, asked about allergies. Pt. stated KNDA. I triple checked the MAR. And administered the medication. Almost immediately pt. expressed inability to breathe and throat swelling. IV infusion was stopped immediately. Raised Pt. to a high fowlers position. Started pt. on non-rebreather and called provider. Called provider. New orders provided. Administered epinephrine 1:1000, 0.5 mg IM. Administered Diphenhydramine 50 mg IV push once. Albuterol 5mg in 3mL NS nebulized. Ranitidine 50 mg IV infused over 30 minutes. And Methylprednisolone 125 mg IV push once. Re-assessed VS at this time.

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