NURSING 340 Medical_Scenario_1_Kenneth_Bronson
Patient Introduction
Kenneth Bronson is a 27-year-old male who was just admitted to the Medical Unit
... [Show More] from the Emergency Department. He presented to the Emergency Department two hours ago with chest tightness, difficulty breathing, a productive cough for a week, and fever. Chest x-ray revealed right lower lobe pneumonia. IV was started of normal saline at 75 mL per hour. He is receiving oxygen at 2 L/min per nasal cannula. SpO2 on room air was 90%, which increased to 95% with supplemental oxygen. He had a temp of 102.6°F and was given acetaminophen 1,000 mg in the Emergency Department. Pharmacy just delivered the antibiotics to be given.
Pharmacology:
Acetaminophen Acetaminophen Ceftriaxone Ceftriaxone Diphenhydramine Diphenhydramine Epinephrine Epinephrine Methylprednisolone Methylprednisolone Ranitidine Ranitidine
Patient information :
27- year-old male with c/o chest tightness, difficulty breathing, a productive cough for a week now and fever
Anticipated physical findings:
➢ Cough, which may produce greenish, yellow or even bloody mucus
➢ Fever, sweating and shaking chills
➢ Shortness of breath
➢ Rapid, shallow breathing
➢ Sharp or stabbing chest pain that gets worse when you breathe deeply or cough
➢ Loss of appetite, low energy, and fatigue Primary Dx: Pneumonia
Describe pathological events associated with the patient’s disease process or condition.
Pneumonia is a pulmonary infection that is characterized by the inflammation of the lung parenchyma.The inflammation could occur due to a bacterial, viral, or fungal infection. At times, one may develop this infection after being admitted to a hospital for the treatment of another condition. Under such circumstances, one is diagnosed with hospital-acquired pneumonia.
When the infection is acquired outside a hospital, due to contact with an infected individual, one is diagnosed with community-acquired pneumonia. Aspiration pneumonia occurs due to the aspiration of a foreign object or the contents of the stomach into the lower respiratory tract. On the basis of anatomy, pneumonia is classified into lobar, lobular, interstitial, and miliary pneumonia.
Causal Organisms for Pneumonia.
The causative organism in more than half of the cases of pneumonia is a bacterium called
Streptococcus pneumoniae. Other bacteria that might be responsible for causing this lung condition include Haemophilus influenzae, Moraxella catarrhalis, Mycoplasma pneumoniae, Legionella, Chlamydia, Klebsiella, Staphylococcus aureus, and Pseudomonas aeruginosa.
Diagnostic test and reason for test :
● Blood tests to confirm the infection and to try to identify the germ that is causing your illness.
● Chest X-ray to look for the location and extent of inflammation in your lungs.
● Pulse oximetry to measure the oxygen level in your blood. Pneumonia can prevent your lungs from moving enough oxygen into your bloodstream.
● Sputum test on a sample of mucus (sputum) taken after a deep cough, to look for the source of the infection.
● CT scan of the chest to get a better view of the lungs and look for abscesses or other complications.
● Arterial blood gas test, to measure the amount of oxygen in a blood sample taken from an artery, usually in your wrist.
● Pleural fluid culture, which removes a small amount of fluid from around tissues that surround the lung, to analyze and identify bacteria causing the pneumonia.
● Bronchoscopy, a procedure used to look into the lungs airways.
Nursing interventions:
➢ Administer oxygen along with medication therapy to assist with relief of symptoms.
➢ Promote airway clearance and elevate head of bed
➢ Encouraging coughing and deep breathing
➢ Optimize fluid balance
➢ Promote rest
➢ Promote nutrition
➢ Administer antibiotics in a timely fashion, draw troughs appropriately
➢ Educate patient and loved ones on the importance of energy conservation, effective airway clearance, nutrition, as well as coughing and deep breathing
vSim ISBAR ACTIVITY INTRODUCTION
Your name, position (RN), unit you are working on:
Kate Orafunam, RN - Medical unit
SITUATION
Patient’s name, age, specific reason for visit:
Kenneth Bronson, 27-year-old male, c/o chest pain, diaphoresis, and shortness of breath.
BACKGROUND
Patient’s primary diagnosis, date of admission, current orders for patient: Dx: Pneumonia
Admitted on 5/11/20
Orders : Regular diet, up as tolerated, vital signs with SpO2 every 4 hours, oxygen at 2 L/min per nasal cannula to maintain SpO2 greater than 92%, IV normal saline at 75ml/hr, ceftriaxone 1 g IVPB every 12 hours, Tylenol 1000mg po every 6 hours PRN
ASSESSMENT
Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs:
Mr. Bronson’s airway maintained SpO2 95% on nasal cannula with humidifier, BP 138/78, HR 90, Resp 18, ECG has regular sinus rhythm and patient states breathing is much
better.
Education about the incident
Any orders or recommendations you may have for this patient:
● Monitor for rebound anaphylaxis.
● Educate patient and loved ones on the importance of energy conservation, effective airway clearance, nutrition, as well as coughing and deep breathing
Pharm4fun Worksheet
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION: Methylprednisolone Classification: Corticosteroids Glucocorticoids Prototype: Prednisone
Safe Dose or dose range, Safe routes:
4 to 48 mg PO daily depending on the disease treated 4 to 120 mg acetate IM daily
Purpose of taking this medication:
Severe inflammation or immunosuppression
PATIENT EDUCATION WHILE TAKING THIS MEDICATION:
● Alert: Counsel patient to discuss benefits and risks and other possible treatments with health care providers before undergoing epidural corticosteroid injection.
● Tell patient not to stop drugs abruptly or without the prescriber's consent.
● Instruct patient to take oral form of a 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 the prescriber about vitamin D or calcium supplement.
● Instruct patient to avoid exposure to infections (such as chickenpox or measles) and to contact the prescriber if such exposure occurs.
Medication: Acetaminophen Classification: Analgesics Prototype: Tylenol
Safe Dose or dose range, safe routes:
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.
Purpose for taking this medication: mild pain or fever Patient Education:
● Tell parents to consult a prescriber before giving drugs to children younger than age 2.
● Advise parents that drug is only for short-term use; urge them to consult prescriber if giving to 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 not to use for marked fever (temperature higher than 103.1° F
● 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 the drug appears in human milk at low levels. Drug may be used safely if therapy is short-term and doesn’t exceed recommended doses.
Medication: Ceftriaxone
Classification: anti-infective, third generation cephalosporin Prototype: third generation cephalosporin
Safe Dose or dose range, safe routes: 1-2 grams for every 12-24 hours, IM/IV
Purpose for taking this medication: Bacterial action against susceptible bacteria such as gram-negative pathogens.
Patient Education:
● Instruct patient to take medication around the clock and to finish the medication completely.
● Take missed dose as soon as possible, unless it is almost time for the next dose; DO NOT double dose
● Advise patient to report signs of superinfection
● Instruct patient to notify HCP if rash, fever and diarrhea develop, especially if stools contain blood, pus, or mucus. Advise patient not to treat diarrhea without
● consulting HCP
Medication: Epinephrine
Classification: anti-asthmatics, bronchodilator, vasopressor Prototype: Adrenergic
Safe Dose or dose range, safe routes: 0.3-0.5 mg SubQ or IM
Purpose for taking this medication:
Management of severe allergic reactions
Patient Education:
● Instruct patient to contact health care professional immediately if shortness of breath is not relieved by medication or is accompanied by diaphoresis, dizziness,
● palpitations, or chest pain
● Do not spray inhaler near eyes
● Advise patient to use bronchodilator first, allow 5 min elapse before administering other inhalant medication
● Advise patient to rinse mouth after each use
Medication: Diphenhydramine
Classification: allergy, cold and cough remedies, antihistamines, antitussives Prototype: Benadryl
Safe Dose or dose range, safe routes: 25-50 mg every 4 hours as needed IM, IV
Purpose for taking this medication: Management of severe allergic reactions
Patient Education:
● May cause drowsiness. Caution to avoid patient from driving or other activities
● May cause dry mouth; perform mouth care
● Teach sleep hygiene techniques
● Advise patient to use sunscreen and protective clothing to prevent photosensitivity reactions
● Caution patient to avoid use of alcohol and other CNS depressants
Medication: Ranitidine
Classification: Anti-ulcer drugs, H2- receptor antagonists Prototype: Zantac
Safe Dose or dose range, safe routes: 150 mg PO every 24 hours or 50 mg IV every 18 to 24 hours
Purpose for taking this medication:
➢ Active duodenal and gastric ulcer
➢ Maintenance therapy for duodenal or gastric ulcer
➢ Hypersecretory conditions, such as Zollinger-Ellison syndrome
➢ GERD
➢ Erosive esophagitis
➢ Heartburn
Patient Education:
● Instruct patient on proper use of OTC preparation, as indicated.
● Remind patient to take a 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
Student Name: Kate Orafunam Assigned vSim: Kenneth Bronson Initials:KB
Age: 27 M/F: M
Code Status: Full
Diagnosis:PN
Length of Stay: 1 day HCP: Sarah Davis
Consults:
Respiratory Isolation: None Fall Risk: No Transfer:
IV Type:
Normal saline
Location: Right Hand Fluid/Rate: 75 mL/ hour Critical Labs:
WBC – 14.3
HCT – 48%
Platelets- 457
Other Services:
Respiratory therapists
Consults Needed:
Infectious disease Pulmonologist and Cardiologist
Allergies:
Ceftriaxone
Student own words:
Why is your patient in the hospital (Answer in your own words and include the History of present Illness):
The patient is admitted due to SOB, and productive cough for over a week. Patient
states difficulty of breathing
Health History/Comorbidities (that relate to this hospitalization):
Patient has a history of productive cough due to pneumonia for a week. Patients smoke 2 packs a day for 10 years.
Shift Goals/ Patient Education Needs:
1. Smoking cessation
2. Patient needs understanding of pneumonia physiology and why it is so important to do breathing exercises and using incentive spirometer
3. 3. Patient need to expectorate secretions
4. 4. Patient needs to report fever, chest tightness, shortness of breath, and sudden confusion
Path to Discharge: Patient has no fever or cough, his lungs are clear to auscultation, SpO2 is 98% on room air. Chest X-ray reveals no signs of infiltration
Path to Death or Injury:
Noncompliance to medication regimen Noncompliance to smoking cessation
Alerts:
What are you on alert for with this patient? (Signs & Symptoms)
1. Fever
2. Fatigue, Headache (due to impaired gas exchange)
3. Shortness of breath
What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?)
1. Temperature
2. Oxygen Saturation
3. Respiratory rate
List Complications that may occur related to dx, procedure, comorbidities:
1. atelectasis
2. Sepsis
3. Lung abscesses
What nursing or medical interventions may prevent the above Alert or complications?
1. Physical activity
2. Antibiotics to treat infection
3. Inhaled medications
4. Monitor vitals every hour
5. Standard precaution
6. Hydration
Management of Care: What needs to be done for this Patient Today?
1. Administer antibiotic
2. Administer oxygen
3. Assist with ADLs
4. Monitor temperature
5. Breathing exercises – incentive spirometer
6. Patient education
Priorities for Managing the Patient’s Care Today
1. Administer oxygen
2. Administer antibiotic
3. Monitor temperature
4. Patient education
What aspects of the patient care can be Delegated and who can do it?
● PCA to monitor patients temperature
● Breathing exercises, the PCA can remind the patient to perform breathing exercises every hour.
Documentation Assignment
1. Document Kenneth Bronson’s new allergy information in his patient record. Allergy: Ceftriaxone
2. Document your initial focused respiratory assessment of Kenneth Bronson. audible wheezing in the chest with increased respiratory effort.
3. Document the assessment changes that occurred before and after the anaphylactic reaction. Respiration was labored and after severe SOB
4. Identify and document key nursing diagnoses for Kenneth Bronson. Impaired gas exchange
5. Referring to your feedback log, document the nursing care you provided.
Guided Reflection Questions
1. How did the scenario make you feel? Focused and organized
2. What signs and symptoms led you to the conclusion that Kenneth Bronson was experiencing an allergic reaction? Severe SOB, decrease in oxygen level
3. Discuss the differences between mild, moderate, and severe anaphylactic reactions. Allergic reactions can be mild, moderate or severe. Most allergic reactions have mild to moderate symptoms, generally involving just one part of the body. For example, if you have a food allergy you probably experience gastrointestinal symptoms; and if you are allergic to something like latex your skin is most likely to show the results when you touch it. However, if you have a severe allergic reaction, many different parts of the body can be affected at the same time, and it can be life-threatening.
4. Discuss the importance of follow-up assessments post-reaction.
Follow up assessments are vital because there may be a need for secondary doses of Epinephrine if symptoms do not resolve with the first dose. Also, delayed reactions can occur and must be monitored for
5. What further needs does Kenneth Bronson have at the end of the scenario that future nursing care should address?
A need for anti anxiety meds because he might have been stressed.
6. Reflect on how you would communicate with family members in an emergency situation if they were present at the bedside.
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?
8. How could you prepare for clinical in order to plan ahead for potential patient emergencies? [Show Less]