Medical Case - Kenneth Bronson Lab

VSIM SIMULATION LAB Medical Case 1: Kenneth Bronson Documentation Assignments 1. Document Kenneth Bronson’s new allergy information in his patient record.  Allergic to Ceftriaxione 2. Document your initial focused respiratory assessment of Kenneth Bronson.  Examined patient’s chest. Patient is breathing 17 breaths per minute. The chest is moving normally on both sides. There is normal skin turgor. He is sweating, and skin is warm. There are reduced breath sounds at the right lung base. Patient stated pain of 2 on the right side of chest. The pain “stings a bit” and does not go anywhere else. Breathing makes pain worse  3. Document the assessment changes that occurred before and after the anaphylactic reaction.  Before the anaphylactic reaction patient had the following vital signs: R:17 per minute, Pulse: 100 per minute, BP: 136/82 mmHg, HR: 98 per minute, Temp: 102°F and SPO2: 92. After the reaction his HR increased to 158 per minute, R: 33 per minute, BP: 148/86 mmHg and SPO2: 90. Deteriorated breathing.  Patient stated that he was not feeling too good. Oxygen level decreased to 85%. There were urticarial rashes on the check. His breathing rate was 36 breaths per minute. The airway sounded obstructed and there was increased respiratory efforts. 4. Identify and document key nursing diagnoses for Kenneth Bronson.  Impaired Gas exchange related to decreased functional lung tissue. Evidence by abnormal breathing patterns, dyspnea, restlessness, and tachycardia. b.Ineffective airway clearance related to allergic airways. Evidence by alterations inrespiratory patterns, diminished breaths sounds, dyspnea, ineffective cough; orthopnea, and restlessness.  5. Referring to your feedback log, document the nursing care you provided. Feedback Log 0:00 You arrived at the patient's side. 0:00 You introduced yourself. 0:10 Patient status - ECG: Sinus rhythm. Heart rate: 96. Pulse: Present. Blood pressure: 139/83 mm Hg. Respiration: 19. Conscious state: Appropriate. SpO2: 95%. Temp: 103 F (39.2 C) 0:11 You washed your hands. To maintain patient safety, it is important to wash your hands as soon as you enter the room. 1:10 Patient status - ECG: Sinus rhythm. Heart rate: 96. Pulse: Present. Blood pressure: 136/81 mm Hg. Respiration: 18. Conscious state: Appropriate. SpO2: 95%. Temp: 103 F (39.2 C) 1:26 You identified the patient. To maintain patient safety, it is important that you quickly identify the patient. 1:45 You obtained informed consent. This is reasonable. 1:58 You asked if the patient was allergic to anything. He replied: 'No, I am not allergic to anything.' 2:05 You asked the patient if he had any pain. He replied: 'Yes, I have some pain.' 2:09 You asked the patient if anything made the pain better. He replied: 'No, not really.' 2:10 Patient status - ECG: Sinus rhythm. Heart rate: 96. Pulse: Present. Blood pressure: 138/82 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 103 F (39.2 C) 2:13 You asked the patient if he could describe his pain. He replied: 'It stings a bit in my chest.' 2:17 You asked the patient if anything made the pain worse. He replied: 'It hurts a bit when I breathe.' 2:21 You asked the patient where the pain was located. He replied: 'It's in the right side of my chest.' 2:24 You asked the patient if the pain went anywhere. He replied: 'No, not really.' 2:28 You asked: How bad is the pain? He replied: 'Not too bad, it's about a 2.' 2:33 You asked the patient how long he had pain for. He replied: 'For about a week.' 2:38 You asked the patient if he needed anything for the pain. He replied: 'No. I'm okay.' 2:49 You asked what happened. He replied: 'The coughing started to get worse, so I thought I'd go to the hospital.' 2:56 You asked the patient when the symptoms started. He replied: 'About a week ago, I started having a fever and a really bad cough' 3:04 You asked: What were you doing when the symptoms started? He replied: 'Nothing special.' 3:08 You asked the patient if he had any difficulty in breathing. He replied: 'Yes, I have been coughing really badly.' 3:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 137/82 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.2 C) 3:15 You asked the patient what other symptoms he had. He replied: 'I feel kind of tired and have some chest tightness.' 3:22 You asked the patient if he had had anything to eat or drink today. He replied: 'I just ate breakfast this morning.' 3:29 You asked the patient if he felt nauseated. He replied: 'No. I don't have any nausea.' 3:34 You asked the patient if he could move his toes. He replied: 'Yes.' 3:38 You asked the patient if he could feel his toes. He replied: 'Yes. I think they are fine.' 3:43 You asked if the patient was allergic to anything. He replied: 'No, I am not allergic to anything.' 3:51 You asked the patient what medication he was taking, if any. He replied: 'No, I don't take any medication.' 3:55 You asked the patient if he had any medical problems. He replied: 'No, I don't have any medical problems.' 3:59 You asked the patient if he was a smoker. He replied: 'Yes. I have been smoking 2 packs a day for the past 10 years.' 4:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 136/81 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C) 4:11 You asked the patient what year it is. He replied: 'The year is 2020.' 4:15 You asked the patient if he knew where he was. He replied: 'I'm at the hospital.' 4:19 You asked the patient what date it was. He replied: 'The 27th' 4:35 You examined the patient's skin. There is normal skin turgor. He is sweating, and his skin is warm. 5:00 You listened to the carotid arteries of the patient. There were only normal sounds. 5:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 136/82 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C) 5:23 You listened to the lungs of the patient. There are reduced breath sounds at the right lung base. 5:46 You listened to the heart of the patient. There were only normal heart sounds. 6:09 You listened to the abdomen of the patient. Normal bowel sounds were heard. 6:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 138/82 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C) 6:16 You looked for normal breathing. He is breathing at 17 breaths per minute. The chest is moving normally on both sides. 6:45 You attached the pulse oximeter. It is a good idea to monitor the saturation and pulse here. This will allow you to reassess the patient continuously. 6:58 You checked the radial pulse. The pulse is strong, 95 per minute and regular. It is correct to assess the patient's vital signs. 7:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 136/81 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C) 7:21 You checked the temperature at the mouth. The temperature was 102 F (39.1 C). 7:40 You checked the eye movements. There was normal range of motion. 7:57 You checked the patient's pupils, and they were 5 mm and reactive. 8:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 137/82 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C) 8:16 You checked the corneal reflex. The corneal reflex was present. 8:33 You checked the eyelash reflex. The eyelash reflex was present. 8:55 You attached the automatic noninvasive blood pressure (NIBP) measurement cuff. This will allow you to reassess the patient continuously. 9:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 135/82 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C) 9:12 You attached a 3-lead ECG. It is correct to attach the monitor to the patient. 9:30 You checked the capillary refill time. The capillary refill time was less than 2 seconds. 9:48 You checked the pedal pulse. The pulse is strong, 95 per minute and regular. 10:1 0 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 137/82 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C) 10:1 1 You assessed the patient's IV. The site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact. This is correct. Assessing any IVs the patient has is always important. 10:1 4 You sat the patient up. It is correct to do so. 11:1 0 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 136/81 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C) 11:2 6 You provided patient education. This is correct. It is important to use every opportunity to provide patient education. 11:4 9 You asked the patient if he needed anything for the pain. He replied: 'No. I'm okay.' 12:1 0 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 133/80 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C) 13:1 0 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 135/80 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C) 14:1 0 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 134/80 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C) 15:1 0 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 135/81 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C) 16:1 0 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 134/80 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C) 17:1 0 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 137/81 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C) 17:5 You asked: How bad is the pain? He replied: 'Not too bad, it's 3 about a 2.' 18:0 1 You asked the patient if he needed anything for the pain. He replied: 'No. I'm okay.' 18:1 0 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 136/82 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C) 18:3 3 You checked the temperature at the mouth. The temperature was 102 F (39.1 C). It is reasonable to check the temperature here. 19:1 0 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 137/82 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C) 20:1 0 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 137/82 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C) 21:1 0 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 137/82 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C) 22:1 0 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 134/80 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C) 23:1 0 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 137/82 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C) 23:3 3 You assessed the patient's IV. The site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact. If you are in doubt, it is always a good idea to reassess any IVs the patient has. 23:5 2 You flushed the cannula. 24:1 0 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 135/81 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C) 24:2 4 You started infusing ceftriaxone. This is part of the correct treatment of this condition, and you typically infuse this over 30 minutes. It is important to use the basic rights of medication administration to ensure proper drug therapy.. 24:2 4 The patient started developing an allergic reaction to the antibiotic. 24:4 4 You stopped infusing ceftriaxone. Correct. It is very important to stop any infusions when an anaphylactic reaction has developed. 25:0 7 You activated the code team. There was no clear indication for this. 25:0 8 Patient status - ECG: Sinus tachycardia. Heart rate: 114. Pulse: Present. Blood pressure: 136/77 mm Hg. Respiration: 22. Conscious state: Appropriate. SpO2: 94%. Temp: 102 F (39.1 C) 25:5 7 Patient status - ECG: Sinus tachycardia. Heart rate: 123. Pulse: Present. Blood pressure: 131/70 mm Hg. Respiration: 27. Conscious state: Appropriate. SpO2: 93%. Temp: 102 F (39.1 C) 26:0 4 You gave the patient 100% oxygen from a non-rebreathing mask. This was part of your orders. 26:3 4 The oxygen rate was 2 L/min. You should use at least 10 L/min of oxygen for the oxygen mask with reservoir. 26:5 7 Patient status - ECG: Sinus tachycardia. Heart rate: 131. Pulse: Present. Blood pressure: 131/67 mm Hg. Respiration: 32. Conscious state: Appropriate. SpO2: 91%. Temp: 102 F (39.1 C) 27:1 7 You phoned the provider in order to discuss the patient. 27:5 7 Patient status - ECG: Sinus tachycardia. Heart rate: 137. Pulse: Present. Blood pressure: 128/62 mm Hg. Respiration: 36. Conscious state: Appropriate. SpO2: 87%. Temp: 102 F (39.1 C) 28:1 3 You administered 0.5 mg of epinephrine 1:1000 intramuscularly. 28:1 9 You placed a nasal oxygen cannula. This was part of your orders. 28:4 8 You flushed the cannula. 28:5 7 A 50 mg dose of diphenhydramine was injected. You should consider administering this drug slowly. It was reasonable to administer an antihistamine here. 28:5 7 Patient status - ECG: Sinus tachycardia. Heart rate: 141. Pulse: Present. Blood pressure: 120/55 mm Hg. Respiration: 36. Conscious state: Appropriate. SpO2: 82%. Temp: 102 F (39.1 C) 29:1 3 You placed a 5 mg dose of albuterol in a nebulizer. It was correct to administer a bronchodilator here. 29:3 9 You started infusing ranitidine. Correct. This was part of your orders.