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.
Feedback Log
, 0:08 You washed your hands. To maintain patient safety, it is
important to wash your hands as soon as you enter the room.
0:10 Patient status - ECG: Sinus rhythm. Heart rate: 96. Pulse:
Present. Blood pressure: 138/82 mm Hg. Respiration: 19.
Conscious state: Appropriate. SpO2: 95%. Temp: 103 F (39.2
C)
0:32 You identified the patient. To maintain patient safety, it is
important that you quickly identify the patient.
0:40 You asked if the patient was allergic to anything. He
replied: 'No, I am not allergic to anything.'
0:55 You sat the patient up. It is correct to do so.
0:59 You looked for normal breathing. He is breathing at 18 breaths
per minute. The chest is moving normally on bothsides.
1:10 Patient status - ECG: Sinus rhythm. Heart rate: 96. Pulse:
Present. Blood pressure: 137/81 mm Hg. Respiration: 18.
Conscious state: Appropriate. SpO2: 95%. Temp: 103 F (39.2
C)
1:29 You attached the pulse oximeter. It is a good idea to monitor the
saturation and pulse here. This will allow you to reassess the
patient continuously.
1:44 You checked the radial pulse. The pulse is strong, 95 perminute
and regular. It is correct to assess the patient's vital signs.
2:10 Patient status - ECG: Sinus rhythm. Heart rate: 96. Pulse:
Present. Blood pressure: 136/81 mm Hg. Respiration: 17.
Conscious state: Appropriate. SpO2: 95%. Temp: 103 F (39.2
C)
2:11 You measured the blood pressure at 136/80 mm Hg. It is
appropriate to monitor the patient by measuring the blood
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.
Feedback Log
, 0:08 You washed your hands. To maintain patient safety, it is
important to wash your hands as soon as you enter the room.
0:10 Patient status - ECG: Sinus rhythm. Heart rate: 96. Pulse:
Present. Blood pressure: 138/82 mm Hg. Respiration: 19.
Conscious state: Appropriate. SpO2: 95%. Temp: 103 F (39.2
C)
0:32 You identified the patient. To maintain patient safety, it is
important that you quickly identify the patient.
0:40 You asked if the patient was allergic to anything. He
replied: 'No, I am not allergic to anything.'
0:55 You sat the patient up. It is correct to do so.
0:59 You looked for normal breathing. He is breathing at 18 breaths
per minute. The chest is moving normally on bothsides.
1:10 Patient status - ECG: Sinus rhythm. Heart rate: 96. Pulse:
Present. Blood pressure: 137/81 mm Hg. Respiration: 18.
Conscious state: Appropriate. SpO2: 95%. Temp: 103 F (39.2
C)
1:29 You attached the pulse oximeter. It is a good idea to monitor the
saturation and pulse here. This will allow you to reassess the
patient continuously.
1:44 You checked the radial pulse. The pulse is strong, 95 perminute
and regular. It is correct to assess the patient's vital signs.
2:10 Patient status - ECG: Sinus rhythm. Heart rate: 96. Pulse:
Present. Blood pressure: 136/81 mm Hg. Respiration: 17.
Conscious state: Appropriate. SpO2: 95%. Temp: 103 F (39.2
C)
2:11 You measured the blood pressure at 136/80 mm Hg. It is
appropriate to monitor the patient by measuring the blood
