Kenneth Bronson - VSIM PDF

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CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (Include Pathophysiology of Disease Process) Pneumonia- infection of the lungs, specifically in the lobes. Can be caused by a virus or fungi. Causes the pt to have a hard time breathing due to the inflammation of the alveoli. Can affect the alveoli in one or both lungs, they fill with fluid making oxygen exchange difficult which is what causes the pt to experience difficulty breathing and rapid, shallow breaths. Aside from the difficulty breathing, other symptoms include productive cough (with phlegm), fever, chills, fatigue and chest pain.

DIAGNOSTIC TESTS (Reason for Test and Results) Chest x-ray- the presence of infiltrates in the lungs identify an infection CBC- pneumonia would result in elevated WBC and increased neutrophils as this would signal that pt’s body is fighting an infection Sputum culture- lab test of the sputum/phlegm, a Gram stain would identify the bacteria causing pt’s infection. Continuous pulse ox- to measure pt’s blood oxygen as pneumonia can keep the lungs from moving enough oxygen into the blood

PATIENT INFORMATION Name: Kenneth Bronson DOB: 10/5/1993 (27y) Gender: Male Height: 180 cm Weight: 74 kg Allergies: no known to pt Adm DX: Pneumonia Adm on: 2/6/2021

ANTICIPATED PHYSICAL FINDING Chest tightness Wheezing lung sounds and difficulty breathing (dyspnea) orthopnea Productive cough Fatigue fever

vSim for ANTICIPATED NURSING INTERVENTIONS AUSCULTATE LUNGS TO ASSESS RATE, RHYTHM AND DEPTH OF RESPIRATIONS OBSERVE SPUTUM FOR COCA ADMINISTER MEDICATIONS PT TEACHING OF DISEASE PROCESS AND DEEP-BREATHING EXERCISES

02 THERAPY MONITOR ABG S & PULSE OX MONITOR VITALS ENCUORAGE AMBULATION AS TOLERATED

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ISBAR ACTIVITY

INTRODUCTION

Student Worksheet

RN in the medical unit

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

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

Kenneth Bronson, 27 YOM. Admitted to the ED w/ chest tightness, difficulty breathing, fever and a productive cough for over a week.

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

Pt was admitted 2/6/2021. Chest X-ray revealed lower right lobe pneumonia. Current doctor’s orders are to maintain SpO2 above 92%. Infuse normal saline at 75 mL/hr. Ceftriaxone 1 g IVPB every 12 hours and Acetaminophen 1000 mg po every 6 hours PRN temp. greater than 101 F. Pt was given acetaminophen & ceftriaxone, Pt started presenting an allergic reaction to the medication. Pt was sat up, put on oxygen and administered Epinephrine IM, albuteral nebulizer, methylprednisolone, diphenhydramine and ranitidine.

ASSESSMENT

Initial pt assessment:

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vSim for Current pertinent assessment data using head-to-toe approach, pertinent diagnostics, vital signs.

Alert and oriented x3 RR: 19 BPM HR: 94 BPM BP: 138/82 Temp: 103 F SpO2: 96% Reduced breath sounds from right lower lobe Normal heart sounds IV site showed no signs of redness, swelling or infiltration

RECOMMENDATION

Encourage ambulation as tolerated Encourage fluids to help decrease secretion thickening Highly recommend smoking sessation and educate pt of the various resources available to assist during this process, such as online groups, local groups, hotlines, nicotine patch, nicotine gum and lozenges.

Any orders or recommendations you may have for this patient

PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE Last Updated 5/6/2021

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vSim for MEDICATION: CEFTRIAXONE

CLASSIFICATION: CEPHALOSPORIN ANITBIOTICS

PROTOTYPE: ROCEPHIN

SAFE DOSE OR DOSE RANGE, SAFE ROUTE 1 g IVPB every 12 hours

PURPOSE FOR TAKING THIS MEDICATION Prescribed to PT for the treatment of suspected bacterial pneumonia

PATIENT EDUCATION W HILE TAKING THIS MEDICATION Report side effects such as diarrhea, prolonged fever, and any signs of allergic reaction

PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE

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vSim for MEDICATION: ACETAMINOPHEN

CLASSIFICATION: ANTIPYRETIC, NON-OPIOID ANALGESIC

PROTOTYPE: TYLENOL

SAFE DOSE OR DOSE RANGE, SAFE ROUTE 1000 mg po every 6 hours PRN temperature greater than 101 F

PURPOSE FOR TAKING THIS MEDICATION Prescribed to patient to treat fever from pneumonia

PATIENT EDUCATION W HILE TAKING THIS MEDICATION Take as directed, advise doctor if fever persists after taking as directed

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vSim for PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: EPINEPHRINE

CLASSIFICATION: ADRENERGICS

PROTOTYPE:

SAFE DOSE OR DOSE RANGE, SAFE ROUTE 1:1000 0.5 mg IM

PURPOSE FOR TAKING THIS MEDICATION Medication was administered for PT’s acute anaphylactic reaction

PATIENT EDUCATION W HILE TAKING THIS MEDICATION Educate PT/family of new allergy information and how the use of prescribed Epi-pen can help provide relief for severe allergic reactions (prescribed as auto-injectors to PTs). Also educate PT how to properly use autoinjector- remove safety cap, place black tip at right angle to leg, press firmly into thigh for 10 seconds, remove and discard properly.

PATIENT EDUCATION WORKSHEET Last Updated 5/6/2021

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vSim for NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: DIPHENHYDRAMINE

CLASSIFICATION: ANTIHISTAMINES

PROTOTYPE: BENADRYL

SAFE DOSE OR DOSE RANGE, SAFE ROUTE 50 mg IV push

PURPOSE FOR TAKING THIS MEDICATION To provide relief of severe allergic symptoms. It was administered to Kenneth to block the histamine released in the immune response with anaphylaxis

PATIENT EDUCATION W HILE TAKING THIS MEDICATION May cause drowsiness and dry mouth. Use of protective clothing and sunscreen should be used while taking medication. Do not consume alcoholic beverages while taking medication.

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vSim for PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: ALBUTEROL

CLASSIFICATION: BRONCHODILATOR

PROTOTYPE: PROVENTIL

SAFE DOSE OR DOSE RANGE, SAFE ROUTE 5 mg in 3 mL normal saline via nebulizer

PURPOSE FOR TAKING THIS MEDICATION To treat PT’s difficulty breathing, coughing, and chest tightness

PATIENT EDUCATION W HILE TAKING THIS MEDICATION Immediately report if shortness of breath is not relieved after using medication or if after using medication pt experiences dizziness, palpittions, or chest pain as these are signs of tachycardia which is a known adverse reaction.

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vSim for PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: RANITIDINE

CLASSIFICATION: H2 BLOCKERS

PROTOTYPE: ZANTAC

SAFE DOSE OR DOSE RANGE, SAFE ROUTE 50 mg IV infused over 30 minutes every 6 hours

PURPOSE FOR TAKING THIS MEDICATION To prevent heartburn and acid indigestions

PATIENT EDUCATION W HILE TAKING THIS MEDICATION May cause constipation, headache, nausea and/or stomach cramps

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vSim for PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: METHYLPREDNISOLONE

CLASSIFICATION: CORTICOSTEROID

PROTOTYPE: MEDROL

SAFE DOSE OR DOSE RANGE, SAFE ROUTE 125 mg IV push

PURPOSE FOR TAKING THIS MEDICATION To decrease inflammation caused by allergic reaction

PATIENT EDUCATION W HILE TAKING THIS MEDICATION May cause upset stomach. Take with food or milk.

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vSim for PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: OXYGEN

CLASSIFICATION: MEDICAL GAS

PROTOTYPE:

SAFE DOSE OR DOSE RANGE, SAFE ROUTE To maintain SpO2 greater than 92%

PURPOSE FOR TAKING THIS MEDICATION To maintain SpO2 level greater than 92%. To supplement PT’s blood oxygen as pneumonia interrupts oxygen exchange due to fluid present in lungs

PATIENT EDUCATION W HILE TAKING THIS MEDICATION How to safely use supplemental oxygen equipment. Advise PT that it is extremely flammable, there should be no smoking or open flames in a room where supplemental oxygen equipment is in use.

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vSim for PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: NORMAL SALINE

CLASSIFICATION:

PROTOTYPE:

SAFE DOSE OR DOSE RANGE, SAFE ROUTE Initial order: 75 mL/hour then updated to 500 mL bolus if needed for hypotension

PURPOSE FOR TAKING THIS MEDICATION Initially administered to maintain blood pressure. Bolus to treat hypotension during anaphylactic reaction

PATIENT EDUCATION W HILE TAKING THIS MEDICATION Possible injection site swelling or redness

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vSim for Nursing Narriative Note: Include initial head to toe assessment which includes Mentation/LOC, eyes, ears, scalp, skin, neck, heart, lungs, abdomen, pelvic, peripheral, ortho, gait. Date/time__02/06/2021 Initial assessment finings: Alert and oriented x3 RR: 19 BPM HR: 94 BPM BP: 138/82 Temp: 103 F SpO2: 96% Reduced breath sounds from right lower lobe Normal heart sounds Administered ordered medications: ceftriaxone 1 g IVPB, acetaminophen 1000 mg Contacted physician to report pt’s adverse reponse After anaphylactic reaction: Pt reported difficulty breathing pt maintained appropriate state of conscious SpO2 87% Administered new medication ordered: epinephrine 1:1000 0.5 mg IM, diphenhydramine 50 mg IV push, albuterol 5 mg in 3 mL saline via nebulizer, rnitidine 50 mg IV, normal saline 500 mL bolus, methylprednisolone 125 mg IV push Contacted physician to update on pt status

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vSim for _ NURSING DIAGNOSIS: ineffective airway clearance and impaired gas exchange

RELATED TO (Include all the reasons for this diagnosis): laryngeal edema

AS EVIDENCED BY (include all the assessment data to support your diagnosis): changes in O2 sat and wheezing lungs sounds GOAL: maintain patent airways and appropriate levels of oxygenation

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vSim for CLINICAL WORKSHEET Dat 2/6/2021 e: Initia ls: Ag 27 e: M/ m F: Code Status: full

Assigned vSim:

Student Name: Diagnosis:

HCP:

Isolation:

pneumonia Length of Stay: Consults: Allergies: ceftriaxone

respiratory

Kenneth Bronson

IV Type:

Critical Labs:

peripheral

Platelets 457 WBC 14.3 HCT 48

Fall Risk:

Location:

yes

Right forearm

Transfer:

Fluid/Rate: NS 75 mL/hr

Other Services

Consults Needed:

Why is your patient in the hospital (Answer in your own words and include the History of present illness)? Pt was admitted from ED after experiencing chest tightness, difficulty breathing, fever and productive cough for over a week. Health History/Comorbidities (that relate to this hospitalization): hx of COPD, Pneumonia, current smoker Shift Goals/ Patient Education Needs: 1. Maintain SpO2, monitor vitals and medicate to treat infection 2.

Educate pt of new allergy information (ceftriaxone) and emergency response (Epi pen)

3.

Educate patient of deep breathing exercises

4.

Educate pt of the importance of smoking cessation

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vSim for Path to Discharge: Pt will understand disease and how lifestyle changes would significantly improve pt health. Pt will be informed of his unknown allergy and what to do in an emergency. Pt will understand meds. Pt vitals will remain stable

Path to Death or Injury:

CLINICAL WORKSHEET Alerts: What are you on Alert for with this patient? (Signs & Symptoms) 1. Increased HR & BP 2. Fever, increased HR & RR, hypotension, confusion, chills 3. Fever, chills, nausea, trouble breathing, rapid HR, confusion What Assessments will you focus on for this patient?

Management of Care: What needs to be done for this Patient Today? 1. Promote patent airways 2. Ambulate pt as tolerated 3. Increase/maintain Sp02 4. Deep breathing exercises 5. Pt education of disease process, meds, allergy, home care 6. Vitals every 4hrs to ensure pt remains stable and pt is responding as anticipated to tx plan

(How will I identify the above signs & symptoms?) 1. Apical pulse, physical assessment 2.

Lactic acid levels, WBC, Vitals

3.

Vitals, WBC

List Complications may occur related to dx, procedure, comorbidities: 1. Tachycardia & hypotension related to nebulizer

Priorities for Managing the Patient’s Care Today 1.

Ensuring pt maintains proper breathing

2.

Sepsis

2.

Medicate to reduce fever

3.

Bacteremia

3.

Assessing pt condition post anaphylactic reaction. Alert for possible complications following nebulizer

What nursing or medical interventions may prevent the Last Updated 5/6/2021

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vSim for above alert or complications? 1. Dilute nebulizer w/ saline 2.

Antibiotics

3.

Proper antibiotics to eliminate infection

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do it? 1. Pt ambulation 2. Providing pt with available smoking cessation options/resources 3.

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