Kenneth Bronson _ Medical Case 1_2020 | Mental Health Case 1_documentation_Graded A

Medical Case 1: Kenneth 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. - - - - - - Continued