kenneth bronson vsim documentation
Elena Miliopulos
Kenneth Bronson Documentation
1. Document Kenneth Bronson’s new allergy information in his patient record.
• He is allergic to ceftriaxone. It was given 1g IV and he started complaining of throat swelling, unable
to breathe. He is also allergic to antibiotic class of cephalosporins.
2. Document your initial focused respiratory assessment of Kenneth Bronson.
• RR 17 per minute, reduced breath sounds in the right lung during auscultation. SpO2 95% through NC
2 L/min. Patient is a smoker and smokes 2 packs of cigarettes for the past 10 years. Complains of
being tired and having chest tightness.
3. Document the assessment changes that occurred before and after the anaphylactic reaction.
• Vitals were stable before reaction- RR 18/min, SpO2 95% NC 2L/min, BP 138/82 mm Hg, temp 102
F, HR 100/min strong and regular. Radial pulse 95 bpm strong, cap refill <2seconds. Skin was warm
to touch a little diaphoretic, normal skin turgor. Pt stated pain 2/10 with chest pain on right side
“stinging”. Normal IV site with no phlebitis, dressing dry and intact, no drainage.
• Vitals after the anaphylactic reaction were RR 21/min, sinus tachycardia present, airway sounded
obstructed and there was an increase in respiratory effort. SpO2 92% with nonrebreather mask
10 L/min, BP 130/72 mm Hg and HR 144/min with rashes noticed 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
• Risk for allergy reaction
• Risk for aspiration
5. Referring to your feedback log, document the nursing care you provided.
• You arrived at the patient's side.
• 0:00 You introduced yourself.
• 0:05 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: 94. Pulse: Present. Blood pressure: 137/82 mm
Hg. Respiration: 19. Conscious state: Appropriate. SpO2: 96%. Temp: 103 F (39.2 C)
• 0:20 You washed your hands.
• 1:10 Patient status - ECG: Sinus rhythm. Heart rate: 94. Pulse: Present. Blood pressure: 138/83 mm
Hg. Respiration: 18. Conscious state: Appropriate. SpO2: 96%. Temp: 103 F (39.2 C)
• 1:33 You identified the patient. To maintain patient safety, it is important that you quickly identify
the patient.
• 1:41 You asked if the patient was allergic to anything. He replied: 'No, I am not allergic to anything.
• 1:53 You sat the patient up. It is correct to do so.
• 1:58 You obtained informed consent. This is reasonable.
• 2:10 Patient status - ECG: Sinus rhythm. Heart rate: 94. Pulse: Present. Blood pressure: 135/80 mm Hg.
Respiration: 17. Conscious state: Appropriate. SpO2: 96%. Temp: 103 F (39.2 C)
• 3:03 You provided patient education. This is correct. It is important to use every opportunity to
provide patient education.
© W o l t e r s K lu w e r H e a l t h | L i
This study source was downloaded by 1000
008 483 9 8 1 1 6 fr om C ou rs eH e ro .c o m o n 0 6 -
p p i n c o tt W i ll ia m s & Wilkins
1 6- 2 02 2 0 9:3 2:2 9 G M T -0 5:00
https://www.coursehero.com/file/61087066/kenneth-bronson-vsim-documentation-docx/
Elena Miliopulos
Kenneth Bronson Documentation
1. Document Kenneth Bronson’s new allergy information in his patient record.
• He is allergic to ceftriaxone. It was given 1g IV and he started complaining of throat swelling, unable
to breathe. He is also allergic to antibiotic class of cephalosporins.
2. Document your initial focused respiratory assessment of Kenneth Bronson.
• RR 17 per minute, reduced breath sounds in the right lung during auscultation. SpO2 95% through NC
2 L/min. Patient is a smoker and smokes 2 packs of cigarettes for the past 10 years. Complains of
being tired and having chest tightness.
3. Document the assessment changes that occurred before and after the anaphylactic reaction.
• Vitals were stable before reaction- RR 18/min, SpO2 95% NC 2L/min, BP 138/82 mm Hg, temp 102
F, HR 100/min strong and regular. Radial pulse 95 bpm strong, cap refill <2seconds. Skin was warm
to touch a little diaphoretic, normal skin turgor. Pt stated pain 2/10 with chest pain on right side
“stinging”. Normal IV site with no phlebitis, dressing dry and intact, no drainage.
• Vitals after the anaphylactic reaction were RR 21/min, sinus tachycardia present, airway sounded
obstructed and there was an increase in respiratory effort. SpO2 92% with nonrebreather mask
10 L/min, BP 130/72 mm Hg and HR 144/min with rashes noticed 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
• Risk for allergy reaction
• Risk for aspiration
5. Referring to your feedback log, document the nursing care you provided.
• You arrived at the patient's side.
• 0:00 You introduced yourself.
• 0:05 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: 94. Pulse: Present. Blood pressure: 137/82 mm
Hg. Respiration: 19. Conscious state: Appropriate. SpO2: 96%. Temp: 103 F (39.2 C)
• 0:20 You washed your hands.
• 1:10 Patient status - ECG: Sinus rhythm. Heart rate: 94. Pulse: Present. Blood pressure: 138/83 mm
Hg. Respiration: 18. Conscious state: Appropriate. SpO2: 96%. Temp: 103 F (39.2 C)
• 1:33 You identified the patient. To maintain patient safety, it is important that you quickly identify
the patient.
• 1:41 You asked if the patient was allergic to anything. He replied: 'No, I am not allergic to anything.
• 1:53 You sat the patient up. It is correct to do so.
• 1:58 You obtained informed consent. This is reasonable.
• 2:10 Patient status - ECG: Sinus rhythm. Heart rate: 94. Pulse: Present. Blood pressure: 135/80 mm Hg.
Respiration: 17. Conscious state: Appropriate. SpO2: 96%. Temp: 103 F (39.2 C)
• 3:03 You provided patient education. This is correct. It is important to use every opportunity to
provide patient education.
© W o l t e r s K lu w e r H e a l t h | L i
This study source was downloaded by 1000
008 483 9 8 1 1 6 fr om C ou rs eH e ro .c o m o n 0 6 -
p p i n c o tt W i ll ia m s & Wilkins
1 6- 2 02 2 0 9:3 2:2 9 G M T -0 5:00
https://www.coursehero.com/file/61087066/kenneth-bronson-vsim-documentation-docx/
