vSim #6 Jennifer Hoffman

1 vSim #6: Jennifer Hoffman Care of Adults vSim #6: Jennifer Hoffman is a 33-year-old female brought to the Emergency Department by her neighbor. She has a history of asthma since childhood with multiple emergency visits within the last year. She appears to be in respiratory distress, struggling to breathe. She is unable to speak other than simple one-word statements. An infusion of normal saline has been started at a keep-open rate. 1. Pre-simulation quiz 2. vSim (90% or above) 3. Post-simulation quiz 4. Documentation assignment 5. Reflection questions 6. SBAR 7. Concept Map 2 vSim #6: Jennifer Hoffman 1 to 3 3 vSim #6: Jennifer Hoffman 4. Documentation Assignments 1. Document your initial focused respiratory assessment of Jennifer Hoffman. Pt. appears to be in respiratory distress, struggling to breathe or communicate with one-word statements. Her RR is 29 breaths per min with increased respiratory effort; she uses the accessory muscles. There are audible wheezes in the chest; Sp02 78%, and non-productive cough. 2. Identify and document key nursing diagnoses for Jennifer Hoffman.  Ineffective breathing pattern r/t swelling and spasm of the bronchial tubes AEB cough, tachypnea, use of accessory muscles, wheezing, decreased SpO2.  Ineffective airway clearance r/t bronchospasms, increased pulmonary secretions, and ineffective cough AEB adventitious lung sounds (wheezes, rhonchi).   Anxiety r/t respiratory distress AEB dyspnea and restlessness Activity intolerance r/t airway problem AEB prolonged dyspnea d/t an asthma attack, lethargy  Deficient knowledge r/t chronicity of diseases, lack of information sources AEB inability to identify triggers, ineffective self-care, absence of adequate medication for condition. 3. Referring to your feedback log, document the nursing care you provided. Assessed VS and IV patency; monitored SpO2 and maintained oxygen level >92% through nonrebreather mask and NC; monitored ECG; assessed respirations and breaths sounds; examined chest and heart; auscultated lungs and heart; changed bed position; meds administration (short-acting beta2-adrenergic agonists, anticholinergics, and corticosteroids); provided education. 4 vSim #6: Jennifer Hoffman 5. Guided Reflection 1. How did the scenario make you feel? This scenario gave me confidence I’ll be able to provide the quality care a patient needs during an asthma attack. I’m aware that identifying exacerbating factors and timing of symptoms is essential in the treatment process. 2. What assessment findings would indicate that the patient’s condition is worsening? Skin appearance would turn blue in color (sign of cyanosis), would be cold to the touch; around lips and gums pallor would develop. The oxygen saturation would decrease (<92%) indicative for hypoxemia. Her ABGs would show an increasing PaCO2, making her more hypercapnic, and a decreasing PaO2, indicating respiratory acidosis. 3. When a patient develops a rapid onset of shortness of breath, what are the nurse’s immediate priorities? The immediate priority is to keep the airway patent, next is to maintain the SpO2 as high as possible, and to keep the patient calm. The nurse should sit the patient up in High Fowler’s position and administer oxygen as ordered. If the patient is due for another treatment of albuterol, this should be given to dilate the airways. Steroids may be given as well. 4. Review Jennifer Hoffman’s laboratory results. Identify which results are abnormal and discuss how this relates to her clinical presentation and the disease process. Oxygen saturation level is lower than 92% which indicate a deficit in perfusion due to narrowing of airways; Hoffman's most recent arterial blood gas (ABG) compared to her initial ABG showed an increase in PaCO2 to 55 and decrease in PaO2 to 72. The ABGs values indicate her condition 5 vSim #6: Jennifer Hoffman is worsening; she has developed respiratory acidosis and is becoming more hypoxemic. These are signs for potential respiratory failure, and she needs immediate attention. HR:130 is abnormal – the increase in heart rate is a compensatory mechanism the body is using to make up for the decreased oxygen supply while the body has an increase in oxygen demand. 5. What communication techniques are important for an extremely anxious patient who is having difÏculty breathing? Patients who have difÏculty breathing become extremely anxious due to lack of oxygen and an increased heart rate. What the nurse can do is to stay calm and try to ask closed questions that limit the patients’ needs to speak in sentences. It is also important to address their concerns through therapeutic communication and to reassure them they are doing everything to alleviate their symptoms as quickly as possible. 6. What patient teaching priorities would be important for the patient who has experienced an acute exacerbation of asthma? It is important to teach patients about asthma (acute and chronic) as well as the purpose and action of medications, proper inhalation technique of medications, and how to identify and avoid triggers. Patients should be able to monitor peak-flow and understand adherence to the prescribed therapy, preventative measures, and the need to work with the health care team. 7. What resources would you recommend for the patient experiencing asthma? I would recommend the patient to access reputable websites, such as WebMD to access lots of resources and get support. 8. What would you do differently if you were to repeat this scenario? How would your patient care change? 6 vSim #6: Jennifer Hoffman I would have start by checking the patient’s pulse and heart rate before moving to a focused assessment of the lungs. S Situation: What is the situation you are calling about?  Identify self, unit, patient, room number.  Briefly state the problem, what is it, when it happened or started, and how severe. Hello, this is Oana and I am a nursing student calling from 5W with regards to Ms. Hoffman in room 521. Pt. is a 33yo female admitted to the ED earlier today for an acute asthma attack. B Background: Pertinent background information related to the situation could include the following:  The admitÝng diagnosis and date of admission  List of current medications, allergies, IV fluids, and labs  Most recent vital signs  Lab results: provide the date and time test was done and results of previous tests for comparison  Other clinical information  Code status Pt appeared in respiratory distress, reported difÏculty breathing, and has been unable to speak more than 1 word at a time. 6 L of humidified O2 was given via NC and EKG was attached. Normal saline had been running at 25 mL/hr to keep the line patent. 5 mg of albuterol in 3 mL normal saline was nebulized with 500 mcg of ipratropium. 100 mg of methylprednisolone was administered via IV push. Assessment: What is the nurse’s assessment of the situation? Patient is afebrile, skin cool and very sweaty. HR has decreased from 120 to 116. BP has ranged in 130’s over high 70’s but is currently 137/81. A V/S stable: HR 116, BP 137/81, RR 20, O2-sat 98%, temperature 99 F. Audible wheezing upon auscultation. Pt exhibits increased respiratory effort. RR has decreased from highest 32 to currently 20. O2 saturation level has increased from 76% to 98% after medication and O2 administration. 7 vSim #6: Jennifer Hoffman R 6.SBAR Recommendation: What is the nurse’s recommendation or what does he/she want? Examples:  Notification that patient has been admitted  Patient needs to be seen now  Order change I recommend continued monitoring of patient’s respiratory status and continuing with the existing orders. I recommend reinforcing education on use of inhalers and ways to reduce asthma exacerbations (i.e. avoid triggers), and for the provider to come see this patient to discuss medication adjustments. 8 vSim #6: Jennifer Hoffman Risk Factors:  Obesity  Tobacco smoke and or secondhand smoke  Occupational exposures  Rhinitis  Genetics Potential Complications:  Pneumothorax  Cardiac arrythmias  Mucus plugging  Atelectasis  PNA  Hyperglycemia (from medications) Signs & Symptoms:  Dyspnea  Cough, usually worst at night  Wheezing  Sputum  Tightness/pain in chest  SOB Diagnosis: Asthma Labs:     Sputum culture PFT ABGs CBC Definition: chronic disorder of the airways characterized by variable and recurring symptoms, airflow obstruction, bronchial hypereresponsiveness, and an underlying inflammation. Pathophysiology (etiology) Trigger/antigen→ initiates inflammation in bronchial airway → inflammation cascade → chemical mediators (cytokines) → leukocytes, neutrophils, eosinophils → bronchoconstriction, mucus secretion, bronchospasm, swelling → decreased airway lumen → difficulty breathing → coughing, wheezing, SOB, chest tightness Teaching:  Use of inhaler  Exercise  Smoking cessation  Avoid triggers (allergens, cold weather, exercise)  Stress management techniques Diagnostic Procedures:   Spirometry Bronchoprovocat ion testing with methacholine Medications:  NS 25 ml/hr  Albuterol 5mg in 3mL NS  Ipratropium 500mcg  Methylprednisolone 100 mg