enneth Bronson Documentation Assignments

1. Document Kenneth Bronson’s new allergy information in his patient record. Allergic to Ceftriaxone. Given 1g IV @ 1108, Pt c/o of throat swelling, unable to breathe. Allergic to antibiotic class, cephalosporins. 2. Document your initial focused respiratory assessment of Kenneth Bronson. RR 17/min, reduced breath sounds at right lung base upon auscultation. SpO2 95% NC 2 L/min. Pt is a tobacco smoker, “2 packs a day for the past 10 years.” Pt c/o tiredness and chest tightness. 3. Document the assessment changes that occurred before and after the anaphylactic reaction. Before anaphylactic reaction, VS were stable: RR 18/min, SpO2 95% NC 2 L/min, BP 138/82 mm Hg, Temp 102 F, HR 100/min strong and regular. During/after anaphylactic reaction, VS: RR 36/min airway sounds obstructed, increased respiratory effort, SpO2 92% non-rebreather mask 10 L/min, BP 140/80 mm Hg, HR 144/min, urticarial rashes on chest 4. Identify and document key nursing diagnoses for Kenneth Bronson. Ineffective airway clearance Ineffective breathing pattern Impaired gas exchange Decreased Cardiac Output Infection 5. Referring to your feedback log, document the nursing care you provided. 0:00 You arrived at the patient's side. 0:00 You introduced yourself. 0:10 Patient status - ECG: Sinus rhythm. Heart rate: 98. Pulse: Present. Blood pressure: 136/82 mm Hg. Respiration: 19. Conscious state: Appropriate. SpO2: 94%. Temp: 103 F (39.2 C) 0:18 You washed your hands. To maintain patient safety, it is important to wash your hands as soon as you enter the room. 1:10 Patient status - ECG: Sinus rhythm. Heart rate: 97. Pulse: Present. Blood pressure: 137/82 mm Hg. Respiration: 18. Conscious state: Appropriate. SpO2: 95%. Temp: 103 F (39.2 C) 1:32 You identified the patient. To maintain patient safety, it is important that you quickly identify the patient. 1:52 You obtained informed consent. This is reasonable