V Sim Medical Scenario #1- Kenneth Bronson.

a. Document your initial HEAD TO TOE assessment (Kenneth Bronson). BP 136/82mmHG. Temp 102F, Pulse 95, Resp 17. Patient is AAOx4. Speech is clear, no slurring noted. Behavior is appropriate for situation and able to follow verbal commands. PERRLA, 5mm. Carotid arteries are 2+, equal bilateral with no bruits noted. Patient is sweating. Skin is warm to touch, instant turgor recoil with no tenting noted. Patient is sweating. Respirations are even, unlabored, on O2, 93%. Lung sounds are CTA in all fields with no adventitious sounds noted. S1 and S2 heart sounds audible, normal, with no abnormalities noted. Abdomen is soft, round, nontender. Active bowel sounds in all quadrants. Voiding per bathroom privileges. Radial pulses are 2+, equal bilateral. Capillary refill 2 seconds. Peripheral IV @ 75ml/hr Normal Saline located on right hand. No redness, swelling, or infiltration noted. Dressing is dry and intact. No edema noted on lower extremities. Lower extremities are warm to touch with no lesions noted, color is appropriate for ethnicity. Pedal pulses are 2+, equal bilateral. Patient reports pain located in the right side of chest with a stinging sensation. Reports pain 2/10. Patient reports no additional needs at the moment. ------------------------------------------------M.David, BSN Student b. Identify and document key nursing diagnoses for Kenneth Bronson. (At least 3 NANDA nursing diagnosis, with a “related to”.)—Also include the defining characteristics for each diagnosis. 1. Ineffective airway clearance r/t increased sputum production AEB reduced breath sounds at the right lung base. 2. Ineffective breathing pattern r/t bronchoconstriction AEB difficulty breathing. 3. Acute pain r/t inflammation of lung parenchyma AEB reports of discomfort in the right V Sim Medical Scenario #1- Kenneth Bronson. VSim Assignment Student Name: c. Document the teaching that you would provide for Kenneth Bronson prior to discharge. (At least three major teaching points in full sentences. Describe the teaching as you would have to describe it to a patient). 1. Get plenty of rest. Getting enough sleep will give your body the strength it needs to fight the illness. 2. Take deep breaths and cough several times each hour to loosen up mucus and get it out of your lungs. 3. Drink several glasses of water a day. Fluids help thin and loosen up the mucus in your lungs and throat. 4. Wash your hands with soap and water or use an alcohol-based hand rub after blowing your nose or using the bathroom, and before eating. d. Document your handoff report in the situation-background-assessmentrecommendation (SBAR) format to communicate what further care Kenneth needs. (S) Situation – The time is 1830. The date is 04/01/2020. The patient is 27-year-old male, Kenneth Bronson. He is a full code. He was just admitted to the Medical Unit from the Emergency Department. Arrived at the Emergency Department with chest tightness, difficulty breathing, a productive cough for a week, and fever. He is being treated for right lower lobe pneumonia, confirmed by xray. He is allergic to Ceftriaxone. Given 1G IV @ 1108, patient complained of throat swelling, unable to breathe. I contacted his PCP and notified him of the anaphylactic reaction. PCP ordered Epinephrine, Albuterol, Diphenhydramine, Ranitidine, Methylprednisolone to be administered to the patient. I’ve attached a 3-lead ECG to monitor his heart and a nonrebreather mask @ 10L/min, SpO2 92%.