Kenneth Bronson VSIM 1 - Lecture Notes. PDF

Preview

Summary

Lecture Notes....

Description

KAREN SALAZAR (KENNETH BRONSON)

CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)

The patient Kenneth Bronson was diagnosed with Pneumonia and Anaphylactic Shock. Pneumonia is inflammation of the lungs caused by bacteria or viral agents. The normal flora found in the lungs is usually altered or resistant which causes a loss of host defenses in the body. Inflammation impairs oxygen ventilation and diffusion from mucosal edema that infiltrates the alveoli. Symptoms include difficulty breathing, cough with sputum, chills, tachypnea, and fever. Anaphylactic shock is a severe allergic reaction that is usually caused by an foreign substance. In this scenario the patient developed an anaphylactic shock due to the antibiotic Ceftriaxone. This is due to activation of antigen-antibody reactions that causes activation of many cytokines and histamine. Signs and symptoms usually occur within 2-30 minutes of ingestion and include: headache, nausea, vomiting, abdominal pain or discomfort, difficulty breathing, laryngeal edema, cardiac dysrhythmias, and hypotension. PATIENT INFORMATION DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) Name: Kenneth Bronson - Sputum culture (shows Age: 27 years old which bacteria caused Allergies: NKDA pneumonia) Diagnosis: Pneumonia - CBC Past History: none - Chest X-ray (reveals where pneumonia is located) - Arterial blood gas (shows oxygen and carbon dioxide levels)

-

ANTICIPATED PHYSICAL FINDINGS

-

Shortness of breath Fever (over 102F) Productive cough Chest tightness

ANTICIPATED NURSING INTERVENTIONS Take vital signs every 4 hours Maintain oxygen saturation rate above 92% Administer antibiotics as prescribed by provider Observe for any signs of anaphylaxis Educate patient about pneumonia and the treatment Contact provider for any alerting changes, especially during an anaphylactic reaction Assess pain levels and provide therapeutic communication

vSim ISBAR ACTIVITY 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 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

STUDENT WORKSHEET “Hello my name is Karen and I am the student nurse working on the Medical Unit from the Emergency department.”

“My patient’s name is Kenneth Bronson, he is 27 years old, and was admitted to the emergency department two hours ago due chest tightness, difficulty breathing, and a productive cough for a week accompanied by fever.” “Chest X-rays revealed right lower lobe pneumonia and he was admitted today. The current orders consist of maintaining oxygen saturation above 92% with nasal cannula, continue IV normal saline at 75 mL per hour, give acetaminophen PRN for fever above 102F, and take vital signs every 4 hours. The provider also prescribed Ceftriaxone antibiotics.”

“Skin is warm, slightly sweating, and intact. Vital signs consist of the following: heart rate 97/min, blood pressure 136/82 mm hg, respiration 19/min, oxygen saturation 95%, temperature 103F, and radial and carotid pulse are 95/min. Heart sounds are normal while breath sounds are reduced at the right lung base. During the anaphylactic shock vital signs consisted of the following: heart rate 136/min, blood pressure 137/71 mm Hg, respiration 32/min, oxygen saturation 91%, temperature 102F, and radial and carotid pulses are strong and 155/min.” “Recommendations would be to continue monitoring vital signs. If patient reports signs of an anaphylactic reaction stop infusion and obtain new orders from provider. Administer new medications as instructed by provider. Place 3 lead EKG leads to monitor for any cardiac dysrhythmias. Once stabilized, educate patient about the anaphylactic reaction and explain that he is allergic to medication and what to do to avoid an event such as this. Continue monitoring oxygen saturation rate by administering oxygen via nasal cannula with warm humidified oxygen. Ask patient how he is feeling and if he reports any new symptoms.”

PHARM-4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: 1. Acetaminophen 2. Ceftriaxone 3. Diphenhydramine 4. Epinephrine 5. Methylprednisolone 6. Ranitidine CLASSIFICATION: 1. Acetaminophen - analgesics and antipyretics 2. Ceftriaxone – cephalosporin antibiotics 3. Diphenhydramine - antihistamines 4. Epinephrine – alpha and beta adrenergic agonists (sympathomimetic agents) 5. Methylprednisolone- glucocorticoids 6. Ranitidine – histamine-2 blockers PROTOTYPE: 1. Acetaminophen – Tylenol, Actamin, Elixsure, Mapap, Medi-tabs, Tactinal, Tycolene, Vitapap 2. Ceftriaxone – Cefotaxime sodium 3. Diphenhydramine – Benadyl, Allergy relief, Allermax, Banophen, Sil[hen cough, etc 4. Epinephrine – Adrenalin, Auvi-Q, Epipen-2 Park, Epinephrinesnap-EMS 5. Methylprednisolone – Medrol, Medrol Dosepak 6. Ranitidine - Zantac SAFE DOSE OR DOSE RANGE, SAFE ROUTE 1. 2. 3. 4. 5.

Acetaminophen – oral: 325mg to 1g orally every 4 to 6 hours Ceftriaxone – 1 to 2 g IV or IM once a day Diphenhydramine – 10 to 50 mg deep IM or IV as needed Epinephrine – 30 kg or greater take 0.3 – 0.5mg IM or subcutaneously Methylprednisolone – high dose therapy 30mg/kg IV over at least 30 minutes every 4-6 hours until condition has stabilized 6. Ranitidine – 150mg orally twice a day for 300mg orally once a day (parenteral is 50mg IM or IV every 6 to 8 hours)

PURPOSE FOR TAKING THIS MEDICATION 1. Acetaminophen – This medication is used to reduce fever and treat mild to moderate pain 2. Ceftriaxone – it is used to treat bacterial infections such as pneumonia. 3. Diphenhydramine – it is an antihistamine that reduces symptoms of allergy such as sneezing, itching, watery eyes, hives, skin rash, and runny nose. 4. Epinephrine – is used to treat severe allergic reactions such as anaphylaxis 5. Methylprednisolone – used to treat inflammatory conditions such as arthritis, lupus, psoriasis, ulcerative colitis and other conditions that affect skin, eyes, lungs, stomach, nervous system, or blood cells 6. Ranitidine – reduces the amount of acid your stomach produces PATIENT EDUCATION WHILE TAKING THIS MEDICATION

1. Acetaminophen – adults and teenagers who weight at least 100 pounds should not take more than 1000mg at one time or more than 4000mg in 24 hours (can cause overdose). Stop medication if you have skin redness or rash that spreads. Be aware for other signs such as nausea, pain in upper stomach, itching, loss of appetite, dark urine, clay colored stools, or jaundice. 2. Ceftriaxone – Be aware of any signs of severe allergic reaction such as seizures, stomach pain, sudden weakness, fever, chills, or cold symptoms, severe pain in upper stomach, and pale or yellowed skin. 3. Diphenhydramine – Possible side effects of pounding heartbeats or flutter, painful or difficult urination, confusion, and tightness in neck or jaw. Must alert provider if you develop any of these symptoms 4. Epinephrine – Alert provider if you are not improving after 20 minutes or if symptoms become worse. 5. Methylprednisolone - be aware of allergic reactions such as swelling, shortness of breath, bruising and thinning of skin, severe depression, black or tarry stools, seizures, and low potassium (leg cramps, constipation, irregular heartbeats, fluttering of chest, increased thirst or urination) 6. Ranitidine – stop medication if you develop these signs of allergic reaction such as hives, difficulty breathing, swelling, stomach pain, dark urine, jaundice, fast or slow heart rate, and easy bruising.

Clinical Worksheet Date: 07/26/2020 Initials: KB

Student Name: Karen Salazar Diagnosis: Pneumonia and Anaphylactic Reaction

HCP: Dr. John Doe

Consults: None

Age: 27 Length of stay: less than

Isolation: Standard Precautions

Fall Risk: High risk

Assigned vSim: Kenneth Bronson IV Type: Peripheral Location: Right hand

Critical Labs: Hematocrit is Other Services: none 48% (elevated), WBC is 14.3 (elevated), and platelets are 457 (elevated) Consults Needed: none

M/F: M Code Status: Full code 1 day

Transfer: Needs assistance

Fluid/Rate: Normal saline 75mL/hour

Allergies: NKDA

Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: Patient presented to the hospital with chest pain, shortness of breath, coughing, and fever.

Health History/Comorbities (that relate to this hospitalization): Current diagnosis – Pneumonia Patient reports to smoke 2 packs of cigarettes everyday for the past 10 years

Shift Goals/ Patient Education Needs: 1. Maintain oxygen saturation above 92% 2. Take vital signs every 4 hours 3. Educate patient on pneumonia and anaphylactic reaction 4. Administer provided medication as prescribed and monitor for side effects Path to Discharge: Patient responded well to medications given to reduce symptoms of anaphylactic reaction and reports improved breathing.

Path to Death or Injury: Patient develops anaphylactic reaction that is unable to be stabilized after medication and oxygen administration.

Alerts: What are you on alert for with this patient? (Signs & Symptoms)

Management of Care: What needs to be done for this Patient Today?

1.

Decreased oxygen saturation (below 92%)

1. Take vital signs every 4 hours

2.

Swelling of the throat and decreased breathing

2. Monitor oxygen and cardiac levels (oxygen must be above 92%) 3. Administer medications as prescribed by provider

3. Changes in vital signs

4. Educate patient about pneumonia and anaphylactic reaction What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?)

5.

Continue normal saline infusion as prescribed

1.

Assess oxygen saturation rates periodically and note for changes

6.

Monitor patient for any new signs and symptoms

2.

Assess for any changes after administering medication

Priorities for Managing the Patient’s Care Today 1. Monitor oxygen and cardiac levels

3.

Observing vital signs closely for any changes 2.

Take vital signs every 4 hours

3.

Educate patient about pneumonia and anaphylactic reaction

4.

Administer medications as prescribed by provider

List Complications that may occur related to dx, procedure, comorbidities: 1.

Hypotension

2.

Bradypnea

3.

Hives

What aspects of the patient care can be Delegated and who can do it? The aspects that can be delegated to include vital signs and monitoring oxygen levels. The nurse is primarily in charge of administering medications, educating the patient, and monitoring cardiac levels.

What nursing or medical interventions may prevent the above Alert or complications?

1.

Continue taking and monitoring vital signs

2.

Continue administering oxygen and note for any changes

3.

Have any medication ready for possible anaphylactic reaction

4.

Call provider if anaphylactic reaction occurs to obtain new orders

Clinical Worksheet

Reflection Questions Paste your reflection questions in the box below

DOCUCARE 1. Vital signs - Vital signs consist of the following: heart rate 97/min, blood pressure 136/82 mm hg, respiration 19/min, oxygen saturation 95%, temperature 103F, and radial and carotid pulse are 95/min. Heart sounds are normal while breath sounds are reduced at the right lung base. During the anaphylactic shock vital signs consisted of the following: heart rate 136/min, blood pressure 137/71 mm Hg, respiration 32/min, oxygen saturation 91%, temperature 102F, and radial and carotid pulses are strong and 155/min.” 2. Focused respiratory assessments - Patient reported pain on the right side of his chest. Pain was 2 in a scale from 1 to 10. The pain has been present for 1 week. Currently reports having difficulty breathing and coughing really badly. He is not taking any medications for it. Nothing makes pain better or worse. Past respiratory history includes smoking 2 packs of cigarretes per day for the last 10 years. Auscultation of lungs sounds shows decreased breath sounds at the right lung base. Patient is breathing at 17 breaths/minute and chest is moving equally on both sides. Pulse oximeter shows oxygen saturation at 95%. 3. Nursing Diagnosis - Ineffective airway clearance related to tracheobronchial infection as evidence by chest x-rays revealing right lobar pneumonia - Risk for impaired gas exchange related to diminished oxygen saturation as evidence by tachycardia and shortness of breath

Clinical Judgement Components Scoring: Exemplary = 4 point Accomplished = 3 points Developing = 2 points Beginning = 1 point Score: vSim 4

Noticing: EAD B

E

EAD B EAD B

A E

Total for category:

11

Focused Observation: Recognizing Deviations from Expected Patterns: Information Seeking:

Interpreting: Prioritizing Data: Making Sense of Data:

EAD B EAD B

E E

Total for category: 8 Responding: Calm, Confident Manner: EAD B Clear Communication: EAD B Well-Planned Intervention/Flexibility: EAD B Being Skillful EAD B

A A A A

Total for category: 12 Reflecting: Evaluation/Self-Analysis: EAD B Commitment to Improvement: E A D B

A E

Total for category: 7

Score: vSim 2

Score: vSim 2...