Immunity (Anaphylaxis) Prep Work Med-Surg Simulation – Anaphylaxis…
QuestionAnswered step-by-stepImmunity (Anaphylaxis) Prep Work Med-Surg Simulation – Anaphylaxis…Immunity (Anaphylaxis) Prep Work Med-Surg Simulation – Anaphylaxis Concept: Immunity Pearson Module 8: Exemplars 8.B – Hypersensitivity Case Study: History of Present Problem: Anna Parker is a 19 year old female who comes to the Emergency room with complaints of throat pain and fever, she feels she may have the flu. She states her sore throat started about a week ago and she just recently developed a fever and chills. She also had nausea and vomiting this morning. Personal/Social History: Anna is at College in Boston studying Bioengineering. She is an international student, as her parents reside in England. Anna states she has no past medical history. Care in the ED: A throat culture is performed along with a rapid strep test which comes back positive. Anna is ordered for PO Amoxicillin and IV fluids. The first dose of antibiotics is given in the ED. What data is important & RELEVANT; therefore it has clinical significance to the nurse? RELEVANT Data from Present Problem:Clinical Significance: RELEVANT Data from Social History:Clinical Significance: What nursing priority(s) captures the your patient’s current status and will guide your plan of care?Current VS: WNL? Significance:T: (oral)101.8 P: (regular)72 R: (regular)14 BP:123/62 O2 sat:100% RA Current Assessment:GENERAL APPEARANCE:Resting comfortably, Pain is 3/10.RESP:Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effortCARDIAC:Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarksNEURO:Alert & oriented to person, place, time, and situation (x4)GI:Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrantsGU:Voiding without difficulty, urine clear/yellowSKIN:Skin integrity intactENT:Lymph nodes are enlarged on palpitation. Throat and tonsils appear red and swollen. What assessment data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Assessment Data:Clinical Significance: Medical Management: Rationale for Treatment & Expected OutcomesCare Provider Orders:Rationale:Expected Outcome: Amoxicillin 500mg PO TID PATIENT CARE: Anna is given Amoxicillin PO and IV fluids. A few minutes later Anna calls the nurse and states she feels like something is wrong. Her throat is itchy and she feels like she cannot breathe. Current VS: WNL? Significance:T: (oral)102 P: (regular)119 R: (regular)26 BP:96/54 O2 sat:92% RA PRIORITY Setting: What Would You Do First and Why? Nursing Priority:Rationale: 1. 2. 3. 4. 5. Medical Management: Rationale for Treatment & Expected OutcomesCare Provider Orders:Rationale:Expected Outcome: 1. Epinephrine2. Albuterol3. Diphenhydramine4. Dexamethasone Lab Results:What lab results are RELEVANT that must be recognized as clinically significant to the nurse?Complete Blood Count (CBC:)Current:High/Low/WNL?Most Recent:WBC (4.5-11.0 mm 3)14.3 Hgb (12-16 g/dL)13 Platelets (150-450 x103/µl)210 Neutrophil % (42-72)42 Band forms (3-5%)3 What lab results are RELEVANT that must be recognized as clinically significant to the nurse?RELEVANT Lab(s):Clinical Significance:TREND: Improve/Worsening/Stable: Basic Metabolic Panel (BMP:)Current:High/Low/WNL?Most Recent:Sodium (135-145 mEq/L)142 Potassium (3.5-5.0 mEq/L)4.1 CO2 (Bicarb) (21-31 mmol/L)26 Glucose (70-110 mg/dL)95 Calcium (8.4-10.2 mg/dL)9 BUN (7-25 mg/dl)10 Creatinine (0.6-1.2 mg/dL)0.9 RELEVANT Lab(s):Clinical Significance:TREND: Improve/Worsening/Stable: 1. What will be the most important discharge/education priorities you will reinforce with their medical condition to prevent future readmission with the same problem? What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient? What is the patient likely experiencing/feeling right now in this situation? What can you do to engage yourself with this patient’s experience, and show that he/she matter to you as a person? SBAR Situation:Background:Assessment:Recommendation: Health ScienceScienceNursingNUR 1035Share Question
