Class notes
Kenneth Bronson VSIM
- Course
- PNUR205
This document provides post scenario documentation and guided reflection of Kenneth Bronson 's case in VSIM Nursing.
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Medical Case 1: Kenneth Bronson - Documentation Assignments1. Document Kenneth Bronson’s new allergy information in his patient record.
Medical unit , Room 123B
07/24/2021 at 1110h
The patient has NKA. but when was given ceftriaxone on the R hand as per Doctor's order, the patient c/ o throat was
swelling and unable to breath suddenly. Upon assessment, RR is 23 bpm. increased respiratory effort noted. urticarial
rashes on the chest. lung airway sounds obstructed upon auscultation. BP 134/72 HR 135 bpm finger, SPO2 94% NC
2L and declining. intermittent coughing present. Primary HCP was called and new orders were given*******L.D. SPN3
2. Document your initial focused respiratory assessment of Kenneth Bronson.
● spo2 95% NC 2L
● rr 17 bpm, chest moving normally bilaterally
● coughing getting worse when asked how the patient is feeling
● lung sounds: reduced breath sounds at the r lung base
● patient smokes 2 packs qd x10 yrs
● stinging chest pain located at R side, level 2/10 that started a week ago.
3. Document the assessment changes that occurred before and after the anaphylactic reaction.
before anaphylactic reaction (1100h) after anaphylactic reaction (1110h)
● spo2 95% NC 2L ● spo2 94% & declining NC 2L
● bp 137/82 sitting LA ● bp: 134/72 sitting LA
● p: 100 bpm, strong, regular radial ● p: 135 finger
● rr: 17 moving normally bilaterally ● rr: 23 bpm, increased resp effort, urticarial rashes on the chest
● temp: 39.1*C ● temp:
● lungs: reduced breath sounds at the r lung base ● lungs: reduced breath sound on the r lung base , the airway sounds obstructed
● c/o of coughing getting worse ● pt c/ o throat swelling & dyspnea, chest tightness
● alert ● e/ of intermittent coughing
● anxious
● patient verbalizes feeling of “lightheadedness”
4. Identify and document key nursing diagnoses for Kenneth Bronson.
● Ineffective Breathing Pattern ● Decreased Cardiac Output
● Impaired Gas Exchange ● impaired skin integrity
● Deficient Knowledge
5. Referring to your feedback log, document the nursing care you provided
● Patient was found in supine position at 11:00
● introduce self, performed hand hygiene, check two identifiers, check allergy and obtain consent prior to care,
● position patient to semi fowlers
● VS + pain (PQRST), orientation and assessed IV access , lung & heart auscultation and attached automatic NIBP, Pulse
ox, ECG monitoring), checked orientation x3, assessed skin
● assessed how the patient is feeling and explored when it started, hx of smoking, meds, other symptoms
● At 11:10, flushed IV, given ceftriaxone as per Doctor's order. then, pt c/ o manifestations of anaphylactic reaction
● D/C’d ceftriaxone, flushed IV
● provided O2 10L of NRBM
● pertinent VS reassessed and called HCP for new orders
● epi, albuterol, methylprednisolone, diphenhydramine was given as per Doctor's order + flush IV
● At 11:16, VS reassessed + heart and lung auscultation + orientation, IV site and infusion, explore how the patient is
feeling
● asked if the patient feels better.
● patient education was provided.
● patient left at sitting position with SPO2 98%
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