Vincent Brody - VSIM PDF

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CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (Include Pathophysiology of Disease Process) COPD- a group of lung diseases, emphysema & chronic bronchitis, that makes it hard for the pt to breath due to inflammatory response to toxins, and also due to pulmonary tissue damage. It can be prevented through lifestyle habits (quitting smoking, avoiding long-term exposure to lung irritants), there is no cure but it is treatable, it is also a chronic and progressive disease. It is most common in older adults—I believe this is because it takes years to develop (progressive) and also because it can be asymptomatic early on. Symptoms include: frequent coughing or wheezing, cough w/ mucus, SOB, whistinling sound during breathing, chest tightness. Emphysema affects the alveoli by damaging it’s wall fibers, this makes them lose their elasticity which in turn prevents them from fully recoiling when the pt exhales. When we exhale we let out carbon dioxide, however in pts with emphysema carbon dioxide is left trapped inside the lungs due to the inability to fully recoil. Bronchitis is the inflammation & thickening of the lung airways as they remain constantly irritated, making it hard ANTICIPATED PHYSICAL DIAGNOSTIC TESTS PATIENT INFORMATION (Reason for Test and Results) FINDING Chest x-ray- can reveal Dyspnea Vincent Brody emphysema. Lungs will look larger Chest discomfort Male than normal, pushing diaghram Wheezing or coughing DOB: 6/23/1953 lower and also flatter. The heart Crackles or wheezes (lung sounds) Height: 172 cm will also look longer. Can also help Elevated HR Weight: 70 kg rule out other diseases. High BP Allergies: No known CT Scan- similar to chest x-ray, High RR Adm on: 2/16/21 but can help diagnose earlier on in Low oxygen saturation level Adm DX: COPD the disease process. Can also be used to measure the extent of the disease. Arterial blood gas (ABG) analysis- to measure levels of oxygen and carbon dioxide. CBC & differential- increased hemoglobin (advanced emphysema) ECG- atrial dysrhythmias (bronchitis), Tall, peaked p waves (bronchitis, emphysema) ANTICIPATED NURSING INTERVENTIONS OBTAIN HEALTH HISTORY MONITOR VITALS ASSESS S&S OF COPD ADMINISTER PRESCRIBED MEDICATIONS ASCULTATE LUNGS & HEART, ASSESS BREATH SOUNDS ECG

& PATTERN

EFFECTIVE BREATHING TECHNIQUES SEND PT FOR X-RAYS, CT SCAN SPUTUM CULTURE OXYGEN THERAPY, MAINTAIN SPO2 LEVELS ABOVE 90% ASSESS PT’S KNOWLEDGE OF DISEASE AND EDUCATE EDUCATE ON MEDICATION, BREATHING EXERCISES, HOME CARE, SMOKING CESSATION REPOSITIONING PT ASSESS PT PAIN LEVEL ASSIST W/ CHEST TUBE INSERTION , THEN MONITOR DRAINAGE AND DRESSING

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Student Worksheet

INTRODUCTION Your name, position (RN), unit you are working on SITUATION Patient’s name, age, specific reason for visit

RN Medical Unit

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

COPD Adm on 2/16/21 Continuous ECG SpO2 monitoring & vital signs every 5min O2 via nasal cannula to keep SpO2 greater than 90% IV: potassium chloride in 5% dextrose and normal saline at 100 mL/hour Arterial blood gas Albuterol 2.5 mg in 3 mL normal saline via nebulizer every 20 mins x 3 doses Chest tube insertion Morphine 2 mg IVP prior to insertion Chest x-ray before and after chest tube insertion

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

Alert & oriented x3 HR: 102 ECG: sinus tachycardia Pulse is present BP: 131/78 RR: 21 SpO2: 93% Temp: 99 F Audible wheezing in chest

RECOMMENDATION Any orders or recommendations you may have for this patient

-Pt should continue current orders and medications -Smoking cessation

Vincent Brody, 67 YOM Admitted by his provider for exacerbation of his COPD

PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE

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vSim for MEDICATION: ALBUTEROL

CLASSIFICATION: BRONCHODILATOR

PROTOTYPE: ALBUTEROL

SAFE DOSE OR DOSE RANGE, SAFE ROUTE Albuterol 2.5 mg in 3 mL normal saline via nebulizer every 20 mins x 3 doses

PURPOSE FOR TAKING THIS MEDICATION Prescribed to pt due to his exacerbation of COPD. Indications: To control/prevent reversible airway obstruction caused by COPD

PATIENT EDUCATION WHILE TAKING THIS MEDICATION Take as instructed, educated pt correct use of nebulizer. Take albuterol first, then wait 2 mins before taking other inhalant meds. May cause dry mouth, rinse mouth after each use. Notify Dr. if prescribed dose doesn’t provide symptom relief.

PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE

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vSim for MEDICATION: MORPHINE

CLASSIFICATION: OPIOID ANALGESICS

PROTOTYPE: HYDROCODONE

SAFE DOSE OR DOSE RANGE, SAFE ROUTE Morphine 2 mg IVP prior to insertion

PURPOSE FOR TAKING THIS MEDICATION Pain management prior to chest tube insertion

PATIENT EDUCATION WHILE TAKING THIS MEDICATION Take as instructed. May cause dizziness, drowsiness, & hypotension use call bell for assistance when ambulating. May cause respiratory depression, report increased shortness of breath. Nurse will reassess and monitor pt’s RR after administering medication.

Nursing Narriative Note:

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vSim for Include initial head to toe assessment which includes Mentation/LOC, eyes, ears, scalp, skin, neck, heart, lungs, abdomen, pelvic, peripheral, ortho, gait. Date/time 02/16/2016 11am Alert & oriented x3 HR: 102 ECG: sinus tachycardia Pulse is present BP: 131/78 RR: 21 SpO2: 93% Temp: 99 F Audible wheezing in chest Medications administered: SpO2 via nasal cannula, IV potassium chloride 5% dextrose & NS at 100 mL/hr, albuterol 2.5 mg in 3 mL Ns via nebulizer q20min x 3 doses Morphine 2 mg IVP administered prior to chest tube insertion Chest tube inserted Chest x-rays performed before and after chest tube insertion Initial x-ray confirmed pneumothorax Will continue to monitor ECG, vitals, lung sounds and RR.

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vSim for _ NURSING DIAGNOSIS: ineffective airway clearance and impaired gas exchange RELATED TO bronchoconstriction due to COPD AS EVIDENCED by SOB, mucus production and low saturation levels GOAL: improvement in gas exchange, airway clearance, oxygenation to meet pt needs OUTCOME CRITERIA

NURSING ORDERS

RATIONALE

DOCUMENTATION/ EVALUATION

1. PT’s respiratory rate 1. assess and record will remain within RR & depth every established limits until 4hrs hand-of

2. PT’s saturation level will remain greater than 90%

3. PT will report knowledge of disease process and aggravating factors to avoid by the end of shift

To maintain normal RR and/or detect any changes in respiration

2. assess for breathing patterns every 4hrs

Breathing patterns can help identify underlying disease process.

1. use pulse oximetry to check saturation levels and pulse rate

Helps identify intial alterations in oxygenation. Will follow up with ABGs

2. assess ABG levels

Helps monitor oxygenation and ventilation status

1. educate pt on the importance of smoking cessation and provide info. on support groups and other options

Air pollutants, environmental toxins and tobacco smoke can aggravate bronchial irritation which can lead to another COPD exacerbation

2.

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EVALUATION: Assess: -Exposure to risk factors -past medical hx -S&S of COPD -pt’s knowledge of disease -vital signs -breath sounds & pattern

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vSim for CLINICAL WORKSHEET Dat 2/16/2021 e: Initia VB ls: Ag 67y e: M/ M F: Code Status: full

Assigned vSim:

Student Name: Diagnosis:

HCP:

Isolation:

COPD

Critical Labs:

Other Services

Peripheral

Length of Stay:

Fall Risk:

1 day

Consults:

Allergies:

RT

No known

IV Type:

Vincent Brody

Location: Right hand

Transfer:

Fluid/Rate: potassium chloride in 5% dextrose & NS at 100 mL/hr

Consults Needed: Respiratory therapist

Why is your patient in the hospital (Answer in your own words and include the History of present illness)? Pt was admitted from his provider’s officer due to exacerbation of his COPD Health History/Comorbidities (that relate to this hospitalization): 50y hx of smoking, x2 packs daily 2 exacerbations in the last year Shift Goals/ Patient Education Needs: 1. Maintain patent airway 2. Facilitate gas exchange (w/ bronchodilators & supplemental oxygenation) 3. Educate on disease, treatment, and smoking cessation 4. Monitor vitals and pulse-ox levels / pt will maintain SpO2 greater than 90% 5. Pt will remain free of infection

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vSim for Path to Discharge: Pt wil be discharged once vitals are stable withing a normal range. Will show understanding of disease process, tx, medication & home care. Will be given info. on smoking cessation options & help groups. Will demonstrate correct technique of breathing

CLINICAL WORKSHEET Alerts: What are you on Alert for with this patient? (Signs & Symptoms) 1. Signs of infection (fever, chills), drainage (COCA), redness or swelling at site 2. SOB, confusion, rapid breathing 3. Dizziness, fatigue, lightheadedness, clammy skin, cold sweat, SOB, Pain in chest, upper abdominal, left arm or jaw What Assessments will you focus on for this patient?

Management of Care: What needs to be done for this Patient Today? 1. Ascultate lungs 2. Administer prescribed medications 3. Educate pt on the importance of smoking cessation 4. Teach pt proper breathing techniques 5. Monitor vitals & ensure SpO2 is kept greater than 90% 6. Inform pt of importance of flu and pneumonia vaccine

(How will I identify the above signs & symptoms?) 1. Monitor vitals and pt condition, monitor site 2.

Monitor RR

3.

Monitor BP

List Complications may occur related to dx, procedure, comorbidities: 1. Chest tube site infection

Priorities for Managing the Patient’s Care Today 1.

Monitor vitals, ECG, and respiratory status

2.

Respiratory failure (from COPD, morphine)

2.

Monitor for signs of infection

3.

Heart attack (low oxygen, hypoxia)

3.

Oxygen therapy to keep SpO2 greater than 90%

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

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What aspects of the patient care can be Delegated and who can do it?

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Assess dressing often to ensure it is kept clean, dry & intact

2.

Monitor for changes in RR and Pt condition. Maintain patent airways

3.

Monitor BP & Ensure prescribed oxygenation needs are met

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1. 2. 3.

X-rays to radiology tech , labs to lab tech Respiratory therapy Repositioning pt & personal hygiene

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