NURSING 341- vSim Clinical Packet - Kenneth Bronson / NURSING341- vSim Clinical Packet - Kenneth Bronson

CONCEPT MAP WORKSHEET

DESCRIBE DISEASE PROCESS AFFECTING PATIENT
(INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
Pneumonia is an infection of the lungs that may be caused by bacteria, viruses, or fungi. The infection causes
the lungs' air sacs (alveoli) to become inflamed and fill up with fluid or pus. That can make it hard for the
oxygen you breathe in to get into your bloodstream. The symptoms of pneumonia can range from mild to
severe, and include cough, fever, chills, and trouble breathing.
Anaphylaxis is caused by an allergen which results in a possibly life-threatening reaction. The body, in response
to an allergen, releases histamine. The histamine has several effects that include restriction of the bronchioles
and edema, as well as pruritus. Allergen can be in the form of food, environmental allergens like pollen, or from
medications.
Learn About Pneumonia. (n.d.). Retrieved from https://www.lung.org/lung-health-diseases/lung-disease-
lookup/pneumonia/learn-about-pneumonia

DIAGNOSTIC TESTS PATIENT INFORMATION ANTICIPATED PHYSICAL
(REASON FOR TEST AND FINDINGS
 RESULTS)
Chest X-Ray – to check for Kenneth Bronson
 Productive cough
pneumonia 27 years old male
 Fever
 ECG monitoring Who was admitted to the
 Fatigue
hospital after his cough
persisted for a week and was
diagnosed with pneumonia.




ANTICIPATED NURSING INTERVENTIONS

 Administer medication as prescribed
 Vital signs with SpO2 every 4 hours
 IV infusion of normal saline 500 ml bolus if needed for hypotension
 Continue regular diet
 Cardiac and respiratory monitoring
 Educate patient on allergic reaction of antibiotic named ceftriaxone and how to care and avoid
any drugs with cephalosporins.

, vSim ISBAR ACTIVITY STUDENT WORKSHEET

INTRODUCTION Dan primary nurse at the medical unit in the hospital

Your name, position (RN), unit
you are working on
SITUATION Kenneth Bronson is a 27-year-old male he went to the emergency
department two hours ago with chest tightness, difficulty breathing, and a
Patient’s name, age, specific reason for productive cough for a week, and fever of 102.6 degrees Fahrenheit.
visit
BACKGROUND Chest x-ray revealed right lower lobe pneumonia he was admitted
on6/20/2020 a few hours ago. Current orders:
Patient’s primary diagnosis, date of -diet: regular, activity: up as tolerated, vital signs with SpO2 every 4 hours,
admission, current orders for patient Oxygen to maintain SpO2 greater than 92%, IV infusion of normal saline at
75 ml/hour, Ceftriaxone 1 g IVPB every 12 hours, Acetaminophen 1000 mg
PO every 6 hours PRN (if temperature greater than 101 F)—given at ER prior
to handoff
When given ceftriaxone patient appeared to have am allergic to medication
new orders as followed; Oxygen to SpO2 greater than 92%, Cardiac and
respiratory monitoring, Epinephrine 1:1000 0.5 mg IM, Diphenhydramine 50
mg IV push, Albuterol 5 mg in 3 ml normal saline via nebulizer, Ranitidine 50
mg IV infused over 30 min. every 6 hours, Normal saline 500 ml bolus if
needed for hypotension, and Methylprednisolone 125 mg IV push


ASSESSMENT BP: 136/82
RR: 17 breaths per minute
Current pertinent assessment data SpO2: 95 %
using head to toe approach, pertinent HR: 96 bpm
Temperature: 102 F
diagnostics, vital signs
Normal findings throughout assessment, except for diminished breath sounds
at the right lower lobe of lungs. Chest expansion was symmetrical.



RECOMMENDATION -Smoking cessation
-Chest physiotherapy
-Incentives spirometry
-Suctioning
Any orders or recommendations you -Sputum cultures
may have for this patient -Increase fluids