NURSING 341vSim Clinical Packet_Kenneth Bronson DEEPLY ELABORATED

vSim Clinical Packet_ CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) 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 prurit us. 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 -disease - lookup/pneumonia/learn -about -pneumonia DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) • Chest X-Ray – to check for pneumonia • ECG monitoring PATIENT INFORMATION Kenneth Bronson 27 years old male Who was admitted to the hospital after his cough persisted for a week and was diagnosed with pneumonia. ANTICIPATED PHYSICAL FINDINGS • Productive cough • Fever • Fatigue ANTICIPATED NURSING INTERVENTIONS • 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 Clinical Packet_ 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 productive cough for a week, and fever of 102.6 degrees Fahrenheit. Patient’s name, age, specific reason for 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 ord ers 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 Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs Normal findings throughout assessment, except for diminished breath sounds at the right lower lobe of lungs. Chest expansion was symmetrical. RECOMMENDATION -Smoking cessation -Chest physiotherapy -Incentives spirometry -Suctioning -Sputum cultures -Increase fluids Any orders or recommendations you may have for this patient vSim Clinical Packet_ PHARM -4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Acetaminophen CLASSIFICATION: Antipyretics/Analgesics PROTOTYPE: 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, Safe route: PO, IV, or Rectal PURPOSE FOR TAKING THIS MEDICATION Use for mild to moderate pain and reduce fever PATIENT EDUCATION WHILE TAKING THIS MEDICATION • Do not take other medications that contains acetaminophen without medical advice • Avoid taking medication longer than 10 days • Do not use without medical direction for fever persisting longer than 3 days over 103 F • Do not give children more than 5 doses in 24 hours Holland, R. (2007). Pearson Prentice Hall Rob Holland Drug Guide. Retrieved from http://www.robholland.com/Nursing/Drug_Guide/