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