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NURSING 101 - Medical Case 1 , Kenneth Bronson

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Medical Case 1: Kenneth Bronson Documentation Assignments 1. Document Kenneth Bronson’s new allergy information in his patient record. Patient is allergic to ceftriaxone. 2. Document your initia ... l focused respiratory assessment of Kenneth Bronson. Patients respiratory rate 17 bpm. The chest is moving symmetrical bilaterally. There are reduced breath sounds at the right lung base. Oxygen saturation is 95% on 2 liters nasal cannula. 3. Document the assessment changes that occurred before and after the anaphylactic reaction. Vitals were within normal limits before reaction occurred. Once reaction occurred, patient’s oxygen saturation dropped to 91%, heart rate increased to 154 at the highest. Respirations increased to 33 bpm. Blood pressure increased to 147/84 mm Hg. 4. Identify and document key nursing diagnoses for Kenneth Bronson.  Ineffective breathing pattern related to bronchoconstriction secondary to allergic reaction as evidenced by chest tightness, respiratory distress, tachypnea, and wheezing.  Deficient knowledge related to lack of recall of allergies as evidenced by inability to identify allergens.  Impaired gas exchange related to ventilation-prefusion imbalance related to allergen exposure. 4. Referring to your feedback log, document the nursing care you provided. 0:00 Arrived at the patient's side. 0:00 Introduced myself. 0:08 Washed my hands. 0:44 Identified the patient. 0:52 Asked if the patient was allergic to anything. He replied: 'No, I am not allergic to [Show More]

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