JenniferHoffmanVSIMworksheetFINAL.pdf - CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT(INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS A

JenniferHoffmanVSIMworksheetFINAL.pdf - CONCEPT MAP...

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Unformatted text preview: CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) A chronic inflammatory airway disorder, asthma is marked by airway hyperresponsiveness with recurrent episodes of wheezing, coughing, tightness of the chest, and shortness of breath. Typically, these episodes are associated with airflow obstruction that may be reversed spontaneously or with treatment. Asthma involves many pathophysiologic factors, including bronchiolar inflammation with airway constriction and resistance that manifests as episodes of coughing, shortness of breath, and wheezing. Asthma can affect the trachea, bronchi, and bronchioles. Inflammation can exist even though obvious signs and symptoms of asthma may not always occur. Bronchospasms, edema, excessive mucus, and epithelial and muscle damage can lead to bronchoconstriction with bronchospasm. Defined as sharp contractions of bronchial smooth muscle, bronchospasm causes the airways to narrow; edema from microvascular leakage contributes to airway narrowing. Airway capillaries may dilate and leak, increasing secretions, which in turn causes edema and impairs mucus clearance. PATIENT INFORMATION DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) Sputum and blood test --> can reveal elevated eosinophil evel ABG and pulse oximetry --> can reveal hypocarbia (reduced CO2 in the blood), respiratory alkalosis, and hypoxemia (low O2 status) Serum IgE--> could reveal any possible allergies Jennifer Hoffman 33 y/o Female DOB 1/31/1987 Admitted on 7/12/2020 Allergy to Hay Fever Dx: Acute Asthma ANTICIPATED PHYSICAL FINDINGS Tachycardia Dsypnea Diaphoresis Wheezing Use of accessory muscles Hyperresonance Cough ANTICIPATED NURSING INTERVENTIONS Ask the patient during the interview about any allergies before administering any medication. Give prescribed/ordered medication as quick-relief for immediate treatment of asthma symptoms or long-lasting medications in order to successfully control and main persistent asthma. Listen to lung sounds before and after administering medications and respiratory interventions. Give fluids if patent is showing signs and symptoms of dehydration. Educate the patient on signs and symptoms of asthma exacerbation and how to prevent it in the future. vSim ISBAR ACTIVITY INTRODUCTION Your name, position (RN), unit you are working on SITUATION Patient’s name, age, specific reason for visit BACKGROUND Patient’s primary diagnosis, date of admission, current orders for patient ASSESSMENT Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs RECOMMENDATION Any orders or recommendations you mayhave for this patient STUDENT WORKSHEET Peter Rantz RN ER Jennifer Hoffman 33 years old Acute Asthma with associated difficulty breathing and respiratory distress Acute asthma admitted on 7/12/2020 Continous ECG, SpO2 monitoring and V/S every 5 minutes Oxygen is to maintain above 92% IV normal saline at 150 mL/hour Medication: Albuterol 5mg in 3mL normal saline via nebulizer every 20 minutes x 3 doses Ipratropium 500mcg with 1st dose of albuterol Methylprednisolone 100 mg IV push A&O x4 Lung sounds have audible wheezing Heart sounds are normal Rthym is sinus tachycardia HR 117 BP 136/81 Resp 25 SpO2 79% Temp 99F Pulse 101 Skin is cool and very sweaty Capillary refill is less than 2 seconds Administer Albuterol and Ipratropium together via nebulizer for quicker, more effective relief Monitor for improved respiratory status after oxygen therapy and drug administration Educate the patient on environmental factors and other conditions that cause flare ups PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Albuterol ipratropium methyl prednisone CLASSIFICATION: Bronchodilator, beta 2 agonist Anticholinergic corticosteroid PROTOTYPE: Asthma exacerbations—120–180mg/day in divided doses 3–4times/day for 48 hr,then 60–80mg/day Albuterol divided twice daily Ipratropium IM(Adults):Methylprednisolone acetate—40–120mgdaily,weekly,or every 2 wk. Methyl Prednisone SAFE DOSE OR DOSE RANGE, SAFE ROUTE 5mg via nebulizer Inhalant (Adults and Children 12 yr): Metered-dose inhaler (nonacute)—2 inhalations 4 times daily (not to exceed 12 inhales/24 hour or more frequently than 4 tomes) Acute exacerbations—4–8 puffsMEDICATION using a spacer device as needed. PURPOSE FOR TAKING THIS Via nebulization (nonacute)—500 mcgprevent 3–4 times daily. bronchoconstriction caused by asthma or chronic Used as a bronchodilator to control and reversible Via nebulization (acute exacerbations)—500 mcg 30 min doses then q2–4 relief hr as needed. obstructive pulmonary disease. Relaxes smooth muscles of for the 3airway. For quick of acute bronchospasm and for the prevention of exercise induced bronchospasms. Maintenance therapy of reversible airway obstruction due to COPD, including chronic bronchitis and emphysema. Can also be used intranasally for rhinorrhea associated with allergic and non-allergic perennial rhinitis. Treatment of bronchospastic disorders to control the inflammatory response. Used for persistent asthma. Systemic corticosteroids are used only to treat acute exacerbations or severe asthma. PATIENT EDUCATION WHILE TAKING THIS MEDICATION Albuterol is used for acute phase and should not be used too frequently or too high a dose. It can be used as topical administration orwith a nebulizer. If the drug is overused it has adverse CNS effect that cause anxiety and cardiac issues. The patient should immediately report symptoms of insomnia, anxiety, restlessness, palpations and chest pain or seek immediate medical treatment if symptoms worsen or persist. This drug is a short acting muscarinic antagonist (SABA) that prevents bronchoconstriction by blocking the binding of ACH. Thus indirectly cases the airway to relax and dilate. It also helps to dry up secretions. This drug can cause dry mouth or sore throat so patient should brush teeth immediately after use, or chew gum of hard candy. The adverse effects of this drug include nasal congestion, heart palpitations, GI distress, headache, coughing and anxiety This medication may cause pharyngeal irritation, coughing, dry mouth, oral fungal infection. The mouth should be rinse when using in an inhaler to prevent thrush. Patients with diabetes should be educated that this drug can increase glucose levels so increased levels should be reported to healthcare provider. Date: Initials: Age: JH M/F: 33 Code Status: Full Code Student Name: Peter Rantz Diagnosis: Acute Asthma Length of Stay: Admitted 8/12/20 HCP: Consults: Allergies: Hay fever Clinical Worksheet Assigned vSim: Isolation: None Fall Risk: None Transfer: Jennifer Hoffman IV Type: Location: Right peripheral arm/AC Fluid/Rate: 150 mL/hr Critical Labs: No labs drawn SpO2 is low critical value Other Services: Respiratory Therapy. X-ray Consults Needed: Respiratory Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: Patient was brought into the ER by her neighbors for complaints of dyspnea and respiratory distress secondary to acure asthma. Home medications including albuterol provided no immediate relief of symptoms. Health History/Comorbities (that relate to this hospitalization): The patient was diagnosed with asthma as a child and has had multiple ER visits for asthma exacerbation in the past. Shift Goals/ Patient Education Needs: 1. Relieve and maintain control of the respiratory distress. 2. Improve the oxygen saturation. 3. Assess/evaluate patient understanding of asthma. 4. Educate the patient on diagnosis and how to prevent future flare ups and complications of asthma. Path to Discharge: The patient's oxygen saturation has improved and reports no difficulty breathing. The patient is no longer working hard to breathe. She is able to speak in full and complete sentences and ambulate without any worsening respiratory issues. Path to Death or Injury: The patient's airways close or worsening respiratory distress ensures until the patient destabilizes to the point of death. Alerts: What are you on alert for with this patient? (Signs & Symptoms) Clinical Worksheet Management of Care: What needs to be done for this Patient Today? 1. Respiratory failure 1. IV medications need to be given 2. Status Asthmaticus 2. Vital signs monitored every 5 minutes 3.Pneumonia 3. Nebulizer to stabilize O2 levels 4. Auscultation of lung sounds before and after medications What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?) 1. SOB, tachypnea, confusion, cyanosis of mcous membranes 2. Dyapnea, chest tightness, blockage of airway, no wheeze present 3. SOB, chest pain, chills, productive cough, sweating, fatigue, fever, body pain, loss of apetitie 5. Assess patient after oxygen treatments and medications to determine treatment effectiveness 6. Educate the patient Priorities for Managing the Patient’s Care Today 1. Give nebulizer and prescribed asthma medications 2. Monitor vital signs every 5 minutes 3. Auscultate lung sounds List Complications may occur related to dx, procedure, comorbidities: 1. Fatigue 2. What nursing or medical interventions may prevent the above Alert or complications? 1. 2. 4. Obtain health history Decreased lung function 3. Airway obstruction 3. 4. SEE BELOW What aspects of the patient care can be Delegated and who can do it? Vital signs can be delegated to licensed assistive personnel such as an LPN. Respiratory treatments can be delegated to respiratory therapy. 1) Continuous monitoring of vital signs every 5 mins. 2) Determining provoking conditions and avoiding them. 3) Assess for respiratory distress 4) Aadminister medications as prescribed ...
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