Clinical Replacement Packet

vSim ISBAR Activity Introduction (Your name, position (RN), unit you are working on) Dayra Guevara (RN), working in the medical unit floor. Situation Patient’s name, age, specific reason for visit Patient Kenneth Bronson is a 27-year-old male. Patient presented to the emergency department with reporting feeling of chest tightness, difÏculty breathing, fever and productive cough for over one week. Background Patient’s primary diagnosis, date of admission, current orders of patient Assessment Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs The patients primary diagnosis is pneumonia as evidenced by chest x-ray reporting pneumonia in the lower right lobe of lung. Patient was admitted on May 8, 2020. The patients current orders are to maintain SpO2 above 92%. Infuse Normal saline at 75 mL/hr. Antibiotic Ceftriaxone 1g IVP every 12 hours and Acetaminophen 1000 mg po every 6 hours PRN temperature greater than 101F. Patients respiration is 17 BPM, heart rate 96 BPM, Blood pressure is 137/81, SpO2 is 95%. Reduced breath sounds on the right lower lobe of lung. Normal heart sounds present. Patients IV site shows no signs of redness, swelling, or infiltration. Patient reports pain of 2 on a scale of 1-10. Patient has normal skin turgor. Temperature is 102 F. Recommendation Any orders or recommendations you may have for this patient Recommend patient to uptake fluids, if tolerated, in order to keep airway clearance, adequate hydration helps patient to decrease the thickening of secretions. I would teach the patient to avoid smoking. I would also advice the patient that the pneumococcal vaccine helps to prevent pneumonia. The flu vaccine is also recommended to avoid the influenza and the complications that come with it, such as, pneumonia. Patient Education Worksheet Name of medication, classification Medication: Diphenhyrdramine 50 mg IV push Classification: Therepautic: Allergy, cold and cough remedies; antihistiamines, antitussives. Safe dose or dose range, safe route Adults via IM/IV 25-50 Mg q 4 hours as needed, do not exceed 400 mg a day. Purpose of this medication Relief of allergic symptoms caused by histamine release including; Anaphylaxis, seasonal and perennial allergic rhinitis, allergic dermatoses. Parkinson’s disease and dystonic reactions from medications, Mild nightÝme sedation. Prevention of motion sickness. Antitussive (syrup only). Patient education while taking this medication Instruct patient to take medication as instructed to; do not exceed recommended amount. Medication may cause drowsiness, caution patient to avoid driving or operating any other activity requiring alertness. This medication may cause dry mouth, inform the patient that frequent oral rinses, good oral hygiene, and sugarless gum or candy can help alleviate this. Advise patient to use sunscreen and protective clothing to prevent photosensitivity reactions. Caution against use of alcohol. Concept Map Worksheet Describe disease process affecting patient (include pathophysiology of disease process) Pneumonia arises from normal florapresent in patients whose resistance has been altered or from aspiration of flora present in the oropharynx. An inflammatory reaction may occur in the alveoli, producing exudates that interfere with the diffusion of oxygen and carbon dioxide. Due to secretions and mucosal edema, there are areas of the lung that are not adequately ventilated and cause partial occlusion of the alveoli o r bronchi. Venous blood entering the pulmonary circulation passes through the under ventilated areas and travels to the left side of the heart deoxygenated. Diagnostic test (reason for test and results) The diagnosis of pneumonia can be made through many things, such as history taking, particularly a recent respiratory tract infection, physical examination, chest x-ray, fiberoptic bronchoscopy, ABGs or pulse oximetry, CBC, gram stain or culture, pulmonary function studies, and electrolytes. In this case, the patient has low breath sounds in the right lower lobe of the lung and an x-ray helped to confirm the presence of pneumonia. Gender: male Age: 27 DOB: 10/05/1992 Patient information Weight: 74 kg. Admission date: 05/08/2020 Height: 180cm Allergies: Ceftriaxone Anticipated physical findings Some physical findings of pneumonia include shortness of breath, decreased intensity of breath sounds, crackles, wheezes, coughing, tracheal deviation. Anticipated nursing interventions Anticipated nursing interventions is to assess the rate, rhythm and depth of the patient’s respiration, observe chest movement and use of the accessory muscles. Assess patient’s hydration status, observe sputum color, viscosity and odor. Teach and assist patient with proper deep-breathing exercises. Maintain adequate hydration by forcing fluids to at least 3000 mL/day unless contraindicated. Encourage ambulation