CONCEPT MAP WORKSHEET
DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
DIAGNOSTIC TESTS (REASON FOR TEST
... [Show More] AND RESULTS)
PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS
Kenneth Bronson is a 27 year
White blood cell count and differential identifies leukocytosis. Blood
culture tests are positive for the causative organism.
Arterial blood gas
analysis (ABG) values may show hypoxemia. Fungal or acid-fast bacilli cultures identify the etiologic agent. Assay
for Legionella-soluble antigen in urine detects the presence of the antigen. Sputum culture, Gram stain, and smear reveal the infecting organism. Rapid
old male who was admitted to the medical unit from the ED. He presented with chest tightness, difficulty breathing, a productive cough for a week, and fever. Chest x ray revealed right lower lobe pneumonia.
ANTICIPATED NURSING INTERVENTIONS
Fever, sputum production, dullness over the affected area, crackles, wheezing, or rhonci, decreased breath sounds, increased fremitus, tachypnea, use of accessory muscles, diminished gag reflex, orthopnea, myalgia, pharyngitis, bradycardia or tachycardia, tracheal deviation, pleural friction rub, rhinitis, lymphadenopathy
• Give prescribed drugs based on the underlying cause, such as antibiotics for bacterial and Mycoplasma pneumonia and antiviral agents for viral pneumonia.
• Give prescribed IV fluids and electrolyte replacement, initiate IV access if not already available, and maintain IV patency. Provide IV site care according to facility protocol.
• Maintain a patent airway and adequate oxygenation, give prescribed supplemental oxygen based on oxygen saturation levels and ABG results, and give oxygen cautiously if the patient has chronic lung disease. Elevate the head of the bed to maximize chest expansion and to ease the work of breathing.
• Suction the patient, as needed.
• Obtain sputum specimens, as needed.
• Auscultate lung sounds for changes.
• Encourage coughing and diaphragmatic breathing exercises and incentive spirometry; if the patient has copious secretions, perform chest physiotherapy.
• Position the patient to prevent aspiration.
• Take steps to prevent aspiration during NG feedings; if the patient has aspiration pneumonia due to difficulty swallowing, institute aspiration precautions.
• Encourage and assist with early mobilization.
• Provide a high-calorie, high-protein diet of soft, easy-to-chew foods, per the speech therapist's recommendation.
• Give supplemental oral feedings; if the patient can't ingest foods and fluids orally, anticipate enteral tube feedings or parenteral nutrition, if needed.
• Encourage proper respiratory hygiene measures; dispose of secretions properly.
• Provide a quiet, calm environment with frequent rest periods; cluster activities to minimize energy expenditure and decrease oxygen demand.
• Apply antiembolism stockings or sequential compression stockings to prevent VTE.
vSim ISBAR ACTIVITY STUDENT WORKSHEET
INTRODUCTION Hello, my name is Paola and I am the nurse in the Nova Sim Lab taking care of patient in room 212.
Your name, position (RN), unit you are working on
SITUATION Kenneth Bronson is a 27 year old male who was admitted to the medical unit from the ED. He presented with chest tightness, difficulty breathing, a productive cough for a week, and fever.
Patient’s name, age, specific reason for visit
BACKGROUND Patient was admitted on July 25th, 2020 and chest x ray revealed right lower lobe pneumonia. Current orders for patient include regular diet, ambulate as tolerated, vital signs with SpO2 every 4 hours, oxygen via nasal cannula to maintain SpO2 greater than 92%, IV infusion of NS at 75 mL/hour, ceftriaxone 1g IVPB every 12 hours, acetaminophen 1000 mg po every 6 hours PRN temperature greater than 101 F.
Patient’s primary diagnosis, date of admission, current orders for patient
ASSESSMENT Patient is breathing at 17 bpm, heart 96 bpm, pulse is present and storng, BP 134.80, SpO2 95%, and temperature 102 F. Patients lung sounds are reduced at the right lung base. Patient has some pain, reports it stings a bit in his chest and rated it a 2 out of a 0-10 scale. Administered ceftriaxone, as ordered.
Patient started developing an allergic reaction to the antibiotic.
Drug was immediately stopped. Patients VS were: heart rate: 127 bpm, BP 131/69, respiration 30, SpO2: 90%, temp 102 F. 0.5 mg of epinephrine 1:1000 IM was administered, 50 mg dose of diphenhydramine was injected slowly, a 5mg dose of albuterol in a nebulizer was administered, infused ranitidine, as ordered, a bolus of 500 mL NS, given over 15 minutes, and 125 mg of
methylprednisolone was given.
Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs
RECOMMENDATION I recommend continuous monitor of patient, especially after his allergic reaction to the medication. Also, continue include regular diet, ambulate as tolerated, vital signs with SpO2 every 4 hours, oxygen via nasal cannula to maintain SpO2 greater than 92%, IV infusion of NS at 75 mL/hour. Maintain a patent airway and adequate oxygenation, give prescribed supplemental oxygen based on oxygen saturation levels and ABG results. Elevate the head of the bed to maximize chest expansion and to ease the work of breathing. Provide a high-calorie, high-protein diet of soft, easy-to-chew foods, per the speech therapist's recommendation.
Any orders or recommendations you mayhave for this patient
PHARM-4-FUN PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION: acetaminophen
CLASSIFICATION: Analgesics
PROTOTYPE: ACET, Arthritis Pain Relief, Atasol Forte, Fortolin, Ofirmev, Pediatrix, Rapid Action, Taminol, Triaminic Fever Reducer, Tylenol
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
Adults: 325 to 650 mg PO every 4 to 6 hours. Or, two extended-release caplets PO every 8 hours.
Maximum, 3,250 mg daily unless under health care provider supervision, when 4 g daily (immediate-release) may be used. For long-term therapy, don’t exceed 2.6 g daily unless prescribed and monitored closely by health care provider.
Children older than age 12: 325 to 650 mg PO every 4 to 6 hours or 1,300 mg PO every 8 hours (extended-release) p.r.n. Maximum dose for immediate-release is 3,250 mg/24 hours unless under health care provider supervision, when up to 4 g/24 hours may be used. Maximum dose for extended-release is 3,900 mg/24 hours.
PURPOSE FOR TAKING THIS MEDICATION
Mild pain or fever. Thought to produce analgesia by inhibiting prostaglandin and other substances that sensitize pain
receptors. Drug may relieve fever through central action in the hypothalamic heat-regulating center.
PATIENT EDUCATION WHILE TAKING THIS MEDICATION
• Tell parents to consult prescriber before giving drug to children younger than age 2.
• Advise parents that drug is only for short-term use; urge them to consult prescriber if giving to infants for longer than 3 days, children for longer than 5 days, or adults for longer than 10 days.
• Black Box Warning: Advise patient or caregiver that many OTC products contain acetaminophen and should be counted when calculating total daily dose.
• Tell patient to consult prescriber for fever lasting longer than 3 days or recurrent fever.
• Alert: Warn patient that high doses or unsupervised long-term use can cause liver damage. Excessive alcohol use may increase the risk of liver damage. Caution long-term alcoholics to limit drug to 2 g/day or less.
• Caution patient to contact health care provider if signs and symptoms of liver damage (illogical thinking, severe dyspepsia, jaundice, inability to eat, weakness) occur.
• Tell breastfeeding patient that drug appears in human milk in low levels. Drug may be used safely if therapy is short-term and doesn’t exceed recommended doses.
• Alert: Warn patient to stop drug and seek medical attention immediately if rash or other reactions occurs while using acetaminophen.
PHARM-4-FUN PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION: ceftriaxone sodium
CLASSIFICATION: Antibiotics
PROTOTYPE:
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
Adults and children older than age 12: 1 to 2 g IM or IV daily or in equally divided doses every 12 hours. Total daily
dose shouldn’t exceed 4 g. Treat for 4 to 14 days. Complicated infections may require longer treatment.
PURPOSE FOR TAKING THIS MEDICATION
Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal. It is given to treat conditions such as
lower respiratory tract infections, skin and skin structure infections, UTI’s, pelvic inflammatory disease, bacterial septicemia, bone and joint infections and meningitis.
PATIENT EDUCATION WHILE TAKING THIS MEDICATION
• Tell patient to report adverse reactions promptly.
• Instruct patient to report discomfort at IV insertion site.
• If home care patient is diabetic and is testing urine for glucose, tell patient drug may affect results of cupric sulfate tests and to use an enzymatic test instead.
• Tell patient to notify prescriber about loose stools or diarrhea.
PHARM-4-FUN PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION: diphenhydramine hydrochloride
CLASSIFICATION: Antihistamines
PROTOTYPE: Banophen, Benadryl, Children’s Benadryl Allergy, Sominex, Unisom SleepMelts
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
Adults and children age 12 and older: 25 mg (syrup) PO every 4 hours. Don’t exceed 150 mg daily. Or, 25 to 50 mg
(liquid) PO every 4 hours. Don’t exceed 300 mg daily.
PURPOSE FOR TAKING THIS MEDICATION
Can be given for nonproductive cough, nighttime sleep aid, rhinitis, allergy symptoms, motion
sickness and Parkinson disease. Competes with histamine for H1-receptor sites. Prevents, but doesn’t reverse, histamine-mediated responses, particularly those of the bronchial tubes, GI tract, uterus, and blood vessels.
PATIENT EDUCATION WHILE TAKING THIS MEDICATION
• Warn patient not to take this drug with any other products that
contain diphenhydramine (including topical therapy) because of increased adverse
reactions.
• Instruct patient to take drug 30 minutes before travel to prevent motion sickness.
• Tell patient to take diphenhydramine with food or milk to reduce GI distress.
• Warn patient to avoid alcohol and hazardous activities that require alertness until CNS effects of drug are known.
• Tell patient to notify prescriber if tolerance develops because a different antihistamine may need to be prescribed.
• Drug is in many OTC sleep and cold products. Advise patient to consult prescriber before using these products.
• Warn patient of possible photosensitivity reactions. Advise use of a sunblock.
PHARM-4-FUN PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION: epinephrine
CLASSIFICATION: Vasopressors, Adrenergic
PROTOTYPE: Adrenalin, Auvi-Q, EpiPen, EpiPen Jr
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
Adults and children weighing 30 kg or more: 0.3 to 0.5 mg IM or subcut, repeated every 5 to 10
minutes as needed. Maximum single dose is 0.5 mg. Or, 0.3 mg IM or subcut with autoinjector into anterolateral aspect of thigh, through clothing if necessary. Repeat once as needed. More than two sequential doses should only be administered under direct medical supervision.
PURPOSE FOR TAKING THIS MEDICATION
Can be given to treat anaphylaxis, hypotension associated with septic shock, asthma, and cardiac resuscitation.
Relaxes bronchial smooth muscle by stimulating beta2 receptors and alpha and beta receptors in the sympathetic nervous system.
PATIENT EDUCATION WHILE TAKING THIS MEDICATION
• If patient has acute hypersensitivity reactions (such as to bee stings), it may be necessary
to teach patient how to self-inject.
• Instruct patient in autoinjector use. Tell patient to give autoinjector in outer thigh and not into buttock.
• Caution patient or caregiver to only give two sequential doses unless under direct medical supervision. Patient should seek immediate medical care for acute hypersensitivity reactions.
• Tell patient to promptly report all adverse reactions.
PHARM-4-FUN PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION: methylprednisolone
CLASSIFICATION: Corticosteroids, Glucocorticoids
PROTOTYPE: Medrol, Depo-Medrol, Solu-Medrol
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
Adults and children: 4 to 48 mg PO daily depending on the disease treated. After favorable response is noted,
determine maintenance dosage by decreasing until lowest dosage that will maintain adequate clinical response is achieved. Or, 4 to 120 mg acetate IM daily, or 10 to 40 mg succinate IM or IV, with subsequent doses dictated by patient’s clinical response and condition. Or, 4 to 10 mg acetate into small joints, 10 to 40 mg acetate into medium
joints, or 20 to 80 mg acetate into larger joints. Intralesional use is usually 20 to 60 mg acetate. Repeat intralesional and intra-articular injections every 1 to 5 weeks.
PURPOSE FOR TAKING THIS MEDICATION
Given to treat severe inflammation or immunosuppression. Decreases inflammation, mainly by stabilizing leukocyte
lysosomal membranes; suppresses immune response; stimulates bone marrow; and influences protein, fat, and carbohydrate metabolism.
PATIENT EDUCATION WHILE TAKING THIS MEDICATION
• Alert: Counsel patient to discuss benefits and risks and other possible treatments with health care provider before undergoing epidural corticosteroid injection.
• Tell patient not to stop drug abruptly or without prescriber’s consent.
• Instruct patient to take oral form of drug with milk or food.
• Teach patient signs and symptoms of early adrenal insufficiency: fatigue, muscle weakness, joint pain, fever, anorexia, nausea, shortness of breath, dizziness, and fainting.
• Instruct patient to carry or wear medical identification indicating the need for supplemental systemic glucocorticoids during stress. This card should contain prescriber’s name, name of drug, and dosage taken.
• Warn patient on long-term therapy about cushingoid effects (moon facies, supraclavicular fat pad) and the need to notify prescriber about sudden weight gain or swelling.
• Advise patient receiving long-term therapy to consider exercise or physical therapy. Also, tell patient to ask prescriber about vitamin D or calcium supplement.
• Instruct patient to avoid exposure to infections (such as chickenpox or measles) and to contact prescriber if such exposure occurs.
PHARM-4-FUN PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION: ranitidine
CLASSIFICATION: Antiulcer, H2 receptor antagonists
PROTOTYPE: Acid Reducer, Zantac, Zantac 75, Zantac 150, Zantac 300
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
Adults: 150 mg PO b.i.d.; doses up to 6 g or more frequent intervals may be needed in patients with severe disease.
Or, infuse continuously at 1 mg/kg/hour. After 4 hours, if patient remains symptomatic or gastric acid output is greater than 10 mEq/hour, increase dose in increments of 0.5 mg/kg/hour and recheck gastric acid output. Doses up to
2.5 mg/kg/hour and infusion rates up to 220 mg/hour have been used.
PURPOSE FOR TAKING THIS MEDICATION
used to treat ulcers; gastroesophageal reflux disease (GERD), a condition in which backward flow of acid from the
stomach causes heartburn and injury of the food pipe (esophagus); and conditions where the stomach produces too much acid, such as Zollinger-Ellison syndrome
PATIENT EDUCATION WHILE TAKING THIS MEDICATION
• Instruct patient on proper use of OTC preparation, as indicated.
• Remind patient to take once-daily prescription drug at bedtime for best results.
• Instruct patient to take without regard to meals because absorption isn’t affected by food.
• Urge patient to avoid cigarette smoking because this may increase gastric acid secretion and worsen disease.
• Advise patient to report all adverse reactions, especially abdominal pain, blood in stool or emesis, coffee- ground emesis, or black, tarry stools.
Clinical Worksheet
Date: 09/13/2020 Student Name: Paola Ocampo Assigned vSim: Kenneth Bronson
Initials: Diagnosis: Pneumonia HCP: John Doe Isolation: Standard IV Type: Peripher al Location:
R arm
Fluid/Rate: IV infusion of NS at 75mL/hour Critical Labs: Other Services:
K.B
Fall Risk:
Age: 27
M/F: M Length of Stay: Consults: Resp.
team, speech therapists
High rsik Consults Needed:
1 day Allergies:
Code Status: Full code
Transfer:
NKA
Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?:
Patient is in the hospital due to chest tightness, difficulty breathing, a productive cough for a week, and fever. Chest x ray revealed right lower lobe pneumonia.
Health History/Comorbities (that relate to this hospitalization): Patient was diagnosed with right lower lobe pneumonia.
Shift Goals/ Patient Education Needs:
1. disorder, underlying causes, diagnostic tests, and treatment, including respiratory care measures and prevention techniques
2. importance of completing the drug therapy regimen for the required number of days, even if the patient is feeling better
3. possible adverse effects of drug therapy, such as hypersensitivity reactions and GI distress, and the need to notify the health care practitioner if any unusual effects occur
4. coughing and breathing exercises
Path to Discharge:
Antibiotics are effective and patients’ vital signs are stable. Patient understands ways to prevent pneumonia, such as using the incentive spirometer and quit smoking.
Path to Death or Injury:
Patient develops septic chock, hypoxemia, or even respiratory failure which leads to death.
Alerts:
What are you on alert for with this patient? (Signs & Symptoms)
1. Dullness over the affected area
2. Fever
3. Aspiration
What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?)
1. Vital signs and pulse oximetry
2. Respiratory status
3. Oxygen saturation level and results of ABG studies
4. Sputum characteristics
5. Pain level
6. Swallowing ability
List Complications that may occur related to dx, procedure, comorbidities:
1. Septic shock
2. Hypoxemia
3. Respiratory Failure
What nursing or medical interventions may prevent the above Alert or complications?
1. Give prescribed drugs
2. Maintain a patent airway and adequate oxygenation
3. Suction patient, as needed
4. Auscultate lung sounds for changes
Management of Care: What needs to be done for this Patient Today?
1. Regular diet
2. Activity: up as tolerated
4. Vital signs with SpO2 every 4 hours
5. Oxygen to maintain SpO2 greater than 92%
6. IV infusion of NS at 75mL/hour
7. Ceftriaxone 1 g IVPB every 12 hours
8. Acetaminophen 1000mg po every 6 hour PRN temperature greater than 101 F Priorities for Managing the Patient’s Care Today
1. Vital signs with SpO2 every 4 hours
2. Oxygen therapy
3. IV infusion
4. Administer medications
What aspects of the patient care can be Delegated and who can do it?
- A nurse can delegate vital signs with SpO2 to a CP. A CP can additionally help the patient to ambulate early with the help of a nurse or another CP. It is essential that the nurse does everything else, as it is their responsibility to administer medication, oxygen therapy, and continue patient education.
5. Position the patient to prevent aspiration
Clinical Worksheet
Reflected Questions:
1. How did the scenario make you feel?
I – I felt comfortable the second time I tried since I knew what I did wrong the first time. In a real life situation, I would feel comfortable performing the necessary actions.
2. What signs and symptoms led you to the conclusion that Kenneth Bronson was experiencing an allergic reaction?
The patient was having extreme difficulty breathing after the infusion of ceftriaxone was given. He also developed a urticaria rash on his neck. These are signs and symptoms of an allergic reaction.
3. Discuss the differences between mild, moderate, and severe anaphylactic reactions.
Mild anaphylactic reactions have symptoms such as a runny nose, a skin rash or a “strange feeling”. Moderate anaphylactic reactions have symptoms such as swelling of the lips, face and eyes, hives or welts, tingling mouth, or abdominal pain. Severe anaphylactic reactions have symptoms such as hypotension, weak, rapid pulses, constricted airways, etc.
4. Discuss the importance of follow-up assessments post-reaction.
It is important to have follow up assessments post reaction because it is possible for the patient to develop a delayed reaction. So, we must continue to monitor the patient for signs and symptoms of further reaction.
5. What further needs does Kenneth Bronson have at the end of the scenario that future nursing care should address?
Kenneth Bronson would first need his reaction documented and an allergy bracelet placed on him to make sure the rest of the hospital staff is aware of his new allergy. Education to the patient and family about what happened to ensure that this does not occur again in the future. He should also be given education on the medication he is to be receiving and how to take these medications. It is likely that the patient will be receiving an epinephrine pen, so it is necessary for us to educate the patient and family on how to administer this medicine and when it is necessary to do so.
6. Reflect on how you would communicate with family members in an emergency situation if they were present at the bedside.
If the family were present during his anaphylactic reaction, I would calmly inform them that he is having a reaction to the antibiotic he was just given and I would tell them that I am going to do my best to reverse the reaction. I would inform the family that we need to work quickly to be able to help their loved one so I would ask them to step outside with the nurse who is not assisting us in the reversal of this patients anaphylactic episode.
7. After completing the simulation and reflecting on your experience, what would you do differently (or the same) for the patient experiencing acute respiratory distress?
I would make sure to attach a 3-lead ekg right away to have a continuous cardiac monitor going. It is important that I am aware of the patients heart rate and rhythm while I work to reverse his anaphylactic episode.
8. How could you prepare for clinical in order to plan ahead for potential patient emergencies?
One way to always be prepared for an emergency situation is knowing your surroundings and educating yourself on hospital protocols. If you are aware of where emergency equipment is located and what protocols are in order for certain emergencies, you are always prepared for the worst. It is also important to learn from mistakes. Whether they are your own or someone else’s mistakes, it is necessary to take note of them to prevent the same mistake from recurring.
Clinical Judgement Components
Scoring:
Exemplary = 4 point Accomplished = 3 points Developing = 2 points Beginning = 1 point
Noticing: Score: vSim 1 Score: vSim 2 Score: vSim 2
Focused Observation: E A D B 2
Recognizing Deviations from
Expected Patterns: E A D B 2
Information Seeking: E A D B 2
Total for category: 6
Interpreting:
Prioritizing Data: E A D B 2
Making Sense of Data: E A D B 2
Total for category:
4
Responding:
Calm, Confident Manner: E A D B 2
Clear Communication: E A D B 2
Well-Planned Intervention/Flexibility:
E A D B 2
Being Skillful E A D B 2
Total for category:
8
Reflecting:
3
Evaluation/Self-Analysis: E A D B 4
Commitment to Improvement: E A D B
Total for category:
7 [Show Less]