Medical Case 1: Kenneth Bronson
Documentation Assignments
1. Document Kenneth Bronson’s new allergy information in his patient
... [Show More] record.
2. Document your initial focused respiratory assessment of Kenneth Bronson.
3. Document the assessment changes that occurred before and after the anaphylactic reaction.
4. Identify and document key nursing diagnoses for Kenneth Bronson.
5. Referring to your feedback log, document the nursing care you provided.
Feedback Log
4:49 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..
4:49 The patient started developing an allergic reaction to the antibiotic.
5:01 You stopped infusing ceftriaxone. Correct. It is very important to stop any infusions when an anaphylactic reaction has developed.
5:10 Patient status - ECG: Sinus tachycardia. Heart rate: 107.
Pulse: Present. Blood pressure: 134/78 mm Hg. Respiration: 19. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C)
5:11 You phoned the provider in order to discuss the patient. 5:28 You gave the patient 100% oxygen from a non-rebreathing
mask. This was part of your orders.
5:52 Patient status - ECG: Sinus tachycardia. Heart rate: 115.
Pulse: Present. Blood pressure: 135/75 mm Hg. Respiration: 24. Conscious state: Appropriate. SpO2: 95%. Temp: 102 F (39.1 C)
5:54 You attached a 3-lead ECG. It is correct to attach the monitor to the patient.
6:14 You administered 0.5 mg of epinephrine 1:1000 intramuscularly.
6:48 You flushed the cannula.
6:50 Patient status - ECG: Sinus tachycardia. Heart rate: 124.
Pulse: Present. Blood pressure: 128/69 mm Hg. Respiration: 29. Conscious state: Appropriate. SpO2: 96%. Temp: 102 F (39.1 C)
6:56 A 50 mg dose of diphenhydramine was injected. It was
reasonable to administer an antihistamine here.
7:30 You started infusing ranitidine. Correct. This was part of your orders.
7:50 Patient status - ECG: Sinus tachycardia. Heart rate: 145.
Pulse: Present. Blood pressure: 139/79 mm Hg. Respiration: 32. Conscious state: Appropriate. SpO2: 96%. Temp: 102 F (39.1 C)
7:59 You flushed the cannula.
8:07 You administered 125 mg of methylprednisolone. Steroids are part of the correct treatment of anaphylaxis.
8:27 You placed a 5 mg dose of albuterol in a nebulizer. It was reasonable to administer a bronchodilator here. You must balance the risk of tachycardia against the benefit of bronchodilation.
8:40 You looked for normal breathing. There are urticarial rashes on the chest. He is breathing at 33 breaths per minute. The airway sounds obstructed. There is increased respiratory effort.
8:50 Patient status - ECG: Sinus tachycardia. Heart rate: 152.
Pulse: Present. Blood pressure: 143/85 mm Hg. Respiration: 33. Conscious state: Appropriate. SpO2: 97%. Temp: 102 F (39.1 C)
9:13 You measured the blood pressure at 142/84 mm Hg.
9:39 You checked the radial pulse. The pulse is strong, 145 per minute and regular.
9:50 Patient status - ECG: Sinus tachycardia. Heart rate: 142.
Pulse: Present. Blood pressure: 137/80 mm Hg. Respiration: 33. Conscious state: Appropriate. SpO2: 97%. Temp: 102 F (39.1 C)
10:0 You phoned the provider in order to discuss the patient.
9
10:5
0
Patient status - ECG: Sinus tachycardia. Heart rate: 136. Pulse: Present. Blood pressure: 138/77 mm Hg.
Respiration: 33. Conscious state: Appropriate. SpO2: 97%. 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.
11:5
0
Patient status - ECG: Sinus tachycardia. Heart rate: 132. Pulse: Present. Blood pressure: 134/73 mm Hg.
Respiration: 33. Conscious state: Appropriate. SpO2: 97%. Temp: 102 F (39.1 C)
11:5
8
You asked the patient how he felt. He replied: 'It's getting difficult to breathe!'
12:1
9
You asked the patient what other symptoms he had. He replied: 'I feel kind of light-headed.'
12:3
6
A patient handoff was performed.
Anaphylactic reactions may be triggered by medications. Symptoms range from flushing, warmth, urticaria, anxiety, itching, cough, and wheezing, to severe systemic reactions, such as severe bronchospasm, laryngeal edema, acute dyspnea, cyanosis, and hypotension.
Dysphagia, abdominal cramping, vomiting, diarrhea, and seizures with cardiac arrest and coma may follow. Early recognition and withdrawal of the triggering substance is pivotal. Rapid treatment is critical and includes epinephrine, IV fluids, and oxygen. Measurement of vital signs, cardiac monitoring, and pulse oximetry are high priorities. Second-line therapy includes corticosteroids, antihistamines, and asthma medications.
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