vSim Clinical Packet_Kenneth Bronson

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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 depart... ment two hours ago with chest tightness, difficulty breathing, and a productive cough for a week, and fever of 102.6 Patient’s name, age, specific reason for degrees Fahrenheit. visit BACKGROUND Chest x-ray revealed right lower lobe pneumonia he was admitted on6/20/2020 a few hours ago. Current orders: -diet: regular, activity: up as tolerated, vital signs with SpO2 every 4 hours, 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 Patient’s primary diagnosis, date of admission, current orders for patient ASSESSMENT BP: 136/82 RR: 17 breaths per minute SpO2: 95 % HR: 96 bpm Temperature: 102 F Normal findings throughout assessment, except for diminished breath sounds at the right lower lobe of lungs. Chest expansion was symmetrical. Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs RECOMMENDATION -Smoking cessation -Chest physiotherapy -Incentives spirometry -Suctioning -Sputum cultures -Increase fluids Any orders or recommendations you may have for this patient PHARM-4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Acetaminophen CLASSIFICATION: Antipyretics/Analgesics PROTOTYPE: Tylenol SAFE DOSE OR DOSE RANGE, SAFE ROUTE Adults: 325 to 650 mg PO every 4 to 6 hours. Or, two extended-release caplets PO every 8 hours. Maximum, 3,250 mg daily unless under health care provider supervision, Safe route: PO, IV, or Rectal PURPOSE FOR TAKING THIS MEDICATION Use for mild to moderate pain and reduce fever PATIENT EDUCATION WHILE TAKING THIS MEDICATION  Do not take other medications that contains acetaminophen without medical advice  Avoid taking medication longer than 10 days  Do not use without medical direction for fever persisting longer than 3 days over 103 F  Do not give children more than 5 doses in 24 hours Holland, R. (2007). Pearson Prentice Hall Rob Holland Drug Guide. Retrieved from http://www.robholland.com/Nursing/Drug_Guide/ PHARM-4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Ceftriaxone CLASSIFICATION: Antibiotic 3rd generation cephalosporin PROTOTYPE: Cefotaxime sodium SAFE DOSE OR DOSE RANGE, SAFE ROUTE Adults and children older than age 12: 1 to 2 g IM or IV daily or in equally divided doses every 12 hours. Total daily dose shouldn’t exceed 4 g. Treat for 4 to 14 days. Complicated infections may require longer treatment in patients with significant renal disease and hepatic dysfunction, maximum dose is 2 g/day. Route: IV or IM PURPOSE FOR TAKING THIS MEDICATION This antibacterial drug used to treat conditions such as lower respiratory tract infections, skin and skin structure infections, urinary tract infections, pelvic inflammatory disease, bacterial septicemia, bone and joint infections, and meningitis. PATIENT EDUCATION WHILE TAKING THIS MEDICATION  Tell patient to report adverse reactions promptly.  Instruct patient to report discomfort at IV insertion site.  If home care patient is diabetic and is testing urine for glucose, tell patient drug may affect results of cupric sulfate tests and to use an enzymatic test instead.  Tell patient to notify prescriber about loose stools or diarrhea. Holland, R. (2007). Pearson Prentice Hall Rob Holland Drug Guide. Retrieved from [Show More]

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