vSim Clinical Packet Kenneth Bronson. Complete Case Study.DESCRIBE DISEASE PROCESS AFFECTING PATIENT
(INCLUDE PATHOPHYSIOLOGY OF DISEASE
... [Show More] PROCESS)
DIAGNOSTIC TESTS
(REASON FOR TEST AND RESULTS)
PATIENT INFORMATION ANTICIPATED PHYSICAL
FINDINGS
ANTICIPATED NURSING INTERVENTIONS
Pneumonia is an infection of the lungs that may be caused by bacteria, viruses, or fungi. The infection causes
the lungs' air sacs (alveoli) to become inflamed and fill up with fluid or pus. That can make it hard for the oxygen
you breathe in to get into your bloodstream. The symptoms of pneumonia can range from mild to severe, and
include cough, fever, chills, and trouble breathing.
Anaphylaxis is caused by an allergen which results in a possibly life-threatening reaction. The body, in response
to an allergen, releases histamine. The histamine has several effects that include restriction of the bronchioles
and edema, as well as pruritus. Allergen can be in the form of food, environmental allergens like pollen, or from
medications.
Learn About Pneumonia. (n.d.). Retrieved from https://www.lung.org/lung-health-diseases/lung-diseaselookup/pneumonia/learn-about-pneumonia
Chest X-Ray – to check for
pneumonia
ECG monitoring
Kenneth Bronson
27 years old male
Who was admitted to the
hospital after his cough
persisted for a week and was
diagnosed with pneumonia.
Productive cough
Fever
Fatigue
Administer medication as prescribed
Vital signs with SpO2 every 4 hours
IV infusion of normal saline 500 ml bolus if needed for hypotension
Continue regular diet
Cardiac and respiratory monitoring
Educate patient on allergic reaction of antibiotic named ceftriaxone and how to care and avoid
any drugs with cephalosporins.
vSim ISBAR ACTIVITY STUDENT WORKSHEET
INTRODUCTION Dan primary nurse at the medical unit in the hospital
Your name, position (RN), unit
you are working on
SITUATION Kenneth Bronson is a 27-year-old male he went to the emergency
department two hours ago with chest tightness, difficulty breathing, and a
Patient’s name, age, specific reason for productive cough for a week, and fever of 102.6 degrees Fahrenheit.
visit
BACKGROUND Chest x-ray revealed right lower lobe pneumonia he was admitted
on6/20/2020 a few hours ago. Current orders:
-diet: regular, activity: up as tolerated, vital signs with SpO2 every 4 hours,
Oxygen to maintain SpO2 greater than 92%, IV infusion of normal saline at 75
ml/hour, Ceftriaxone 1 g IVPB every 12 hours, Acetaminophen 1000 mg PO
every 6 hours PRN (if temperature greater than 101 F)—given at ER prior to
handoff
When given ceftriaxone patient appeared to have am allergic to medication
new orders as followed; Oxygen to SpO2 greater than 92%, Cardiac and
respiratory monitoring, Epinephrine 1:1000 0.5 mg IM, Diphenhydramine 50
mg IV push, Albuterol 5 mg in 3 ml normal saline via nebulizer, Ranitidine 50
mg IV infused over 30 min. every 6 hours, Normal saline 500 ml bolus if
needed for hypotension, and Methylprednisolone 125 mg IV push
Patient’s primary diagnosis, date of
admission, current orders for patient
ASSESSMENT BP: 136/82
RR: 17 breaths per minute
SpO2: 95 %
HR: 96 bpm
Temperature: 102 F
Normal findings throughout assessment, except for diminished breath sounds
at the right lower lobe of lungs. Chest expansion was symmetrical.
Current pertinent assessment data
using head to toe approach, pertinent
diagnostics, vital signs
RECOMMENDATION -Smoking cessation
-Chest physiotherapy
-Incentives spirometry
-Suctioning
-Sputum cultures
-Increase fluids [Show Less]