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 Medical Surgical Simulation Two: Unfolding case study

You are working at the ER with Ms.Dunning.

 She was admitted at 1000 with complaint of asthma exacerbation of asthma. She is in Fastrack room awaiting a bed on the medical surgical floor.

 After listening to report, what do you believe to be the priorities for care?

 What questions would you have to ask the nurse who is giving report? 

SBAR:  

S: Kimberly Dunning, 20 yr old patient for Dr. Maude Riley admitted this morning with diagnosis of acute exacerbation of asthma

 B. Full code. Sulfa allergies(rash), she was diagnosed with asthma 1 year ago that was well controlled with maintenance inhalers up to 2 months ago when she lost her insurance coverage and could no longer afford her medications. She has been feeling unwell for the last 2 days and has had increasing shortness of breath and coughing spells. She has no other underlying health issues, and she lives at home with a one year old son and her boyfriend. She currently takes only Tylenol and Zyrtec over the counter.

 A. In the ER she had lab work and CXR that had the following abnormalities : WBC’s 11.8, CXR was suggestive of pneumonia. Lung sounds indicates inspiratory and expiratory wheezing, she is coughing up scant amounts of thick yellow-green sputum, O2 sats 92% on 35% Venturi mask, respiratory rate is 24-28 breaths per minute. Skin is intact, Oral cavities noted to be dry but intact, Cardiac shows regular rhythm with rate 100-120’s.

Temperature on arrival was 101.5 Tymp. Blood cultures were drawn and an IV was started to Left Antecubital 18G. Pt received first dose 500mg Levofloxacin at 1200pm. IV infusion of D51/2NS 1L was infused over 4 hours in the ER and she has been started on an infusion of D51/2NS at 125mL/hr. She remains alert and oriented, but is anxious because of her shortness of breath. Her boyfriend is at her bedside. She did receive an Albuterol nebulizer treatment 30 minutes ago with minimal improvement.

 R. Acute exacerbation of asthma, noncompliance with treatment regimen possible pneumonia. Continue to monitor respiratory status closely, provide emotional support and teaching. 

At the bedside:

 Ms. Dunning is resting in bed, head of the bed is at 30 degrees elevation. Her boyfriend is at her side holding her hand.

 Vital signs: T. 101.F P. 116, Resp. 26 BP: 138/82

 Pulse Ox 88% on 28% Venturi mask.

 IV D51/2NS is infusing to Left Antecubital at a rate of 250 mLs/hr.

 She has received an oral dose of prednisone 30mg po and her first dose of Levofloxacin 750mg IVPB

Physical Assessment

 Ms. Dunning has pale skin, and is gripping her boyfriend’s hand tightly.

 She tells you the following:

 ” I thought I would be feeling better by now, this mask doesn’t seem to be helping, I feel like I am smothering.”

 ” I need to get home, my baby needs me.”

 ” Can’t you just give me some inhaler or something and let me go home, this is going to be very expensive.”

The patient is wheezing

Physical assessment

 As you perform a respiratory assessment on Ms. Dunning, you note that she has coarse crackles in the left lower lobe.

 She also demonstrates the following behavior

 She is coughing up small amounts of thick yellow sputum

WHAT SHOULD YOU DO:

 What should you do ?

 List 3 priorities.

â—¦What data do you need to gather?

◦What assessments should you perform?

â—¦What interventions can you provide without a care provider’s order to assist the patient’s breathing?

 

sbar

 Design the SBAR you will use when calling the care provider using the priority areas you identified in your assessment. 

Orders received:

 Place on 50%Venturi mask, titrate to keep O2 sats above 92% or greater.

 Administer albuterol 5mg by nebulizer now.

 Administer ipratropium 0.5mg by nebulizer following Albuterol nebulizer.

 I will be arriving shortly.

Medication Cart:

 Albuterol inhalation is supplied as 0.083% or 2.5mg per 3mL. How many mL’s will the nurse administer?

 What should the nurse prior to administration?

 What contraindications would the nurse assess for when using this medication?

 What steps will the perform during administration of this medication?

 How will the nurse evaluate the effectiveness of the medication?

 Provide an appropriate explanation of the Albuterol and Ipratropium medication to the patient. 

30 minutes later…….

 Patient vital signs :

â—¦T 101F, BP 140/86, P 120, Resp 26 Pulse Ox 96% on 50% Venturi Face mask

â—¦Patient states ” I think I can breathe better now.”

What should you assess on the patient? What are the priorities?

What else can you do to support the patient and family?

SBAR

 Provide an SBAR for the oncoming nursing staff documenting what has happened with this patient.

SCIENCE
HEALTH SCIENCE
NURSING