Medical Case 01 Kenneth Bronson PDF

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Medical Case 1: Kenneth Bronson Documentation Assignments 1. 2. 3. 4. 5.

Document Kenneth Bronson’s new allergy information in his patient record. Document your initial focused respiratory assessment of Kenneth Bronson. Document the assessment changes that occurred before and after the anaphylactic reaction. Identify and document key nursing diagnoses for Kenneth Bronson. Referring to your feedback log, document the nursing care you provided.

1. Document Kenneth Bronson’s new allergy information in his patient record The patient, Kenneth Bronson, was admitted to the hospital 09/08/2020. The patient and his medical records stated that he has no known allergy. During the medication administration the patient experienced allergic reaction on Ceftriaxone. The drug was administered IV. Reaction – anaphylaxis (dyspnea, difficulty breathing, skin rash). Education about class of the drug caused the allergic reaction, symptoms of allergic reaction, and methods of prevention was provided to the patient. The special note about allergy in the patient’s medical chart was made. 2. Document your initial focused respiratory assessment of Kenneth Bronson. The focused respiratory assessment was provided: Pulse oximeter was attached, 95% Respiratory rate – 19 breaths per minute, the chest was moving normally on both sides. Oral temperature – 103 F (39.2 C) The automatic noninvasive blood pressure (NIBP) measurement cuff was attached (138/82 mm Hg). The lungs of the patient were auscultated. There were reduced breath sounds at the right lung base. Normal heart sounds. Heart rate 97 3. Document the assessment changes that occurred before and after the anaphylactic reaction. Initial assessment at 0900: Alert and oriented x 3 Temperature (oral) – 103 F (39.2 C) Respiratory rate - 19 BP (left hand) – 138/82 mm Hg SpO2 – 95%

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Heart rate – 97 beats per minute Pain – location (chest), scored 2 out of 10 Nasal cannula – placement, flow rate (2 L/min) were checked.

0930 (after the anaphylactic reaction): The patient experienced difficulty breathing, skin rash was noted (neck area). Conscious state: appropriate Temperature (oral) – 102 F (39.1 C) Respiratory rate - 37 BP (left hand) – 137/73 mm Hg SpO2 – 88% Heart rate - 148 ECG- Sinus tachycardia.

4. Identify and document key nursing diagnoses for Kenneth Bronson. -

Ineffective breathing pattern related to laryngeal edema and bronchospasm, as evidenced by coughing, dyspnea and tachypnea. Goal- the patient will maintain an effective breathing pattern, as evidenced by normal rate, depth, oxygen saturation level by 1400.

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Impaired gas exchange, related to alveolar hypoventilation, as evidenced by tachypnea, use of accessory muscles. Goal -the pt. will demonstrate improved and adequate oxygenation of tissues by ABG’s within normal parameters and absence of symptoms of respiratory distress by 09/09/2020.

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Decreased cardiac output related to alteration in heart rate and rhythm, decreased oxygenation, as evidenced by tachypnea, dyspnea, and decreased oxygen saturation. Goal- the pt. will display hemodynamic stability (BP, cardiac output, peripheral pulses within normal range) by 1900 09/08/2020

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5.

Referring to your feedback log, document the nursing care you provided.

0900: Initial assessment was provided, VS were obtained, and pain level and location were assessed (the pt. Alert and oriented x 3, Temperature (oral) – 102 F (39.1 C), Respiratory rate – 19, BP (left hand) – 138/82 mm Hg, SpO2 – 95%, Heart rate – 97 beats per minute Pain – location (chest), scored 2 out of 10) - Nasal cannula – placement, flow rate (2 L/min) were checked. - Focused respiratory assessment was done - The pt’s IV site was assessed (the site had no redness, swelling, infiltration, bleeding or drainage) - The pt. was placed in high-Fowler position. 0915: - Ceftriaxone infusion was started (1 g IVPB every 12 hours) as prescribed 0920: - The patient started developing an allergic reaction to the antibiotic. - Ceftriaxone infusion was immediately stopped. - Provider was notified and new order was obtained (by phone) 0925: -

0.5 mg of epinephrine 1:1000 was administered intramuscularly, as prescribed 5 mg dose of albuterol was placed in a nebulizer, as prescribed. A 50 mg dose of diphenhydramine was injected, slowly, as prescribed 125 mg of methylprednisolone was injected, slowly, as prescribed.

Infusion of ranitidine was started, as prescribed.

Reaction of the patient to medication administration was observed. The patient tolerated medication well. 0935: - 3-lead ECG was attached - Patient was educated about his current condition, cause of that allergic reaction, and methods of prevention and managing of allergic reactions. 0940: -

VS and patient’s condition were monitored. 100% oxygen from a non-rebreathing mask was given to the patient (flow rate 10 L/min). Pulse oximeter readings were obtained , SpO2 – 95% Non-rebreathing mask was replaced by simple mask (flow rate 6 L/min) A patient handoff was performed.

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