Florida South Western State College, Lee NUR 1025L,1020JENNIFER HOFFMAN WORKSHEET vSim.ClinicalReplacementStdtWksht.docx JENNIFER HOFFMAN WORKSHEET vSim.Clinical ReplacementStdt Wksht.

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DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) Arterial Blood Gas Analysis:  To evaluate the efficiency ... of pulmonary gas exchange.  to determine the acid base level of blood  to monitor respiratory therapy. PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS ANTICIPATED NURSING INTERVENTIONS Acute Asthma is a chronic inflammatory disorder characterized by the obstruction of airflow. It causes bronchoconstriction, increased mucus production, and hyperresponsiveness of the airway to a variety of stimuli. an asthma attack Can be caused by a respiratory infection, cold weather, physical exertion, some medications, and allergens are common triggers. When bronchoconstrictions occur; it may cause adventitious sounds or abnormal lung sounds which are wheezing as heard through the simulation, cough due to mucus production, and dyspnea which is the difficulty in breathing. Name: Jennifer Hoffman Age: 33 Years old Diagnose with Acute Asthma, The patient has a history of asthma since childhood and was rushed to the emergency room due to experiencing respiratory distress, difficulty breathing, and was not able to speak a simple sentence phrase.  nasal flaring  respiratory depth changes  abnormal breathing patterns  prolonged expiratory phase  adventitious breath sounds such as wheezes  Maintain a continuous monitor of the patient's vital signs. Heart rate, blood pressure, respiration, pulse, and temperature  Auscultate patients' lung sounds to check for any abnormalities or tightness..  Keeping the patient’s bed head elevated allows for adequate diaphragm excursion and lung expansion.  Encourage to practice slow deep breathing. Instruct the patient to purse lips during exhalation because prolonged expiration prevents air trapping  Use short acting-beta-2-antagonist drugs to relax the airway smooth muscles and treatment for acute exacerbation of asthma. administer other medications ordered by the provider such as corticosteroids  Use pulse oximetry to monitor the patient's oxygen saturation to detect changes in the patient’s oxygenation levels that should be maintained at 92% or greater..  Administer Oxygen as needed or as ordered by the provider.  Asses the patient’s IV line for any swelling or redness, and check the laboratory results on arterial blood gas.  Provide patient education on self-care medication and prevention of the diagnosis. vSim ISBAR ACTIVITY STUDENT WORKSHEET INTRODUCTION MARINELLA DENISE CALIMARAN NURSING STUDENT LEVEL 2 Your name, position (RN), unit you are MEDICAL SURGICAL UNIT CLINICAL working on SITUATION Name: JENNIFER HOFFMAN Age: 33 YEARS OLD  The patient was under respiratory distress, difficulty breathing, unable to speak, experiencing anaphylactic shock/ asthma attack. Patient’s name, age, specific reason for visit BACKGROUND DIAGNOSIS: acute asthma DATE: 9/12/2020 ORDERS:  Vital signs must be checked every 5 minutes with continuous ECG, SpO2 monitoring.  Oxygen mask along with Humidified O2 must be administred to raise patient’s SpO2 at a 90%  I.V. normal saline 150mL/hour along with methylprednisone 100g IV push  albuterol 5mL in 3mL normal saline via nebulizer 20 minutes 3x - ipratropium 500mcg within the first dose of albuterol. Patient’s primary diagnosis, date of admission, current orders for patient ASSESSMENT PRIOR TO THERAPEUTIC APPROACH:  patient lung auscultation; there was abnormal lung sounds (wheezing), respirations were at 30 breaths/min, heart rate: 113, B.P. 137/74 mmHg, Conscious state: appropriate, SpO2: 72%, Temp 99. AFTER THERAPEUTIC ADMINISTRATION:  oxygen, IV normal saline with methylprednisone IV push, Albuterol and Ipratropium via nebulizer order medication was administred  patient’s respirations: 20 breaths/min, there were a few/less audible wheezes in the chest, chest moving normally on both sides.  ECG: sinus tachycardia,, Heart Rate: 116, B.P. 137/81 mmHg, Consciousstate: Appropriate. SpO2: 96%, Temp 99F Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs RECOMMENDATION  encourage the patient to practice slow deep breathing during exhalation to produce a positive distending pressure within the bronchioles which helps the bronchioles open.  plan for periods of rest between activities; fatigue can increase the work or breathing.  creat a patient care plan on preventing asthma triggers that correspond with the patient’s lifestyle.  Teach the patient to reinforce the need for taking controller medications as prescribed. [Show More]

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