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Jennifer Hoffman Worksheet v Sim
maternity and pediatrics nursing (2011)
Florida SouthWestern State College
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CONCEPT MAP WORKSHEET
DESCRIBE DISEASE PROCESS AFFECTING PATIENT
(INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
DIAGNOSTIC TESTS
(REASON FOR TEST AND RESULTS)
Arterial Blood Gas Analysis:
To evaluate the eiciency 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 inlammatory disorder characterized by the obstrucion of airlow. It causes bronchoconstricion, increased mucus producion, and hyperresponsiveness of the airway to a variety of simuli. an asthma atack Can be caused by a respiratory infecion, cold weather, physical exerion, some medicaions, and allergens are common triggers. When bronchoconstricions occur; it may cause adveniious sounds or abnormal lung sounds which are wheezing as heard through the simulaion, cough due to mucus producion, and dyspnea which is the diiculty in breathing.
Name: Jennifer Hofman Age: 33 Years old Diagnose with Acute Asthma, The paient has a history of asthma since childhood and was rushed to the emergency room due to experiencing respiratory distress, diiculty breathing, and was not able to speak a simple sentence phrase.
nasal laring respiratory depth changes abnormal breathing paterns prolonged expiratory phase adveniious breath sounds such as wheezes
Maintain a coninuous monitor of the paient's vital signs. Heart rate, blood pressure, respiraion, pulse, and temperature Auscultate paients' lung sounds to check for any abnormaliies or ightness.. Keeping the paient’s bed head elevated allows for adequate diaphragm excursion and lung expansion. Encourage to pracice slow deep breathing. Instruct the paient to purse lips during exhalaion because prolonged expiraion prevents air trapping Use short acing-beta-2-antagonist drugs to relax the airway smooth muscles and treatment for acute exacerbaion of asthma. administer other medicaions ordered by the provider such as coricosteroids Use pulse oximetry to monitor the paient's oxygen saturaion to detect changes in the paient’s oxygenaion levels that should be maintained at 92% or greater.. Administer Oxygen as needed or as ordered by the provider. Asses the paient’s IV line for any swelling or redness, and check the laboratory results on arterial blood gas. Provide paient educaion on self-care medicaion and prevenion of the diagnosis.
PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION: albuterol
CLASSIFICATION: BRONCHODILATORS; ADRENERGICS
PROTOTYPE: Airomir, Proair HFA, Provenil HFA
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
inhalation; ADULTS: 12 years or older given 2 by a nebulizer, given every 5- 15 minutes. Safe route: if there is 1 inhalation ordered, wait at least 2 minutes between inhalations. Shaked the aerosol inhaler well before use and prime inhaler before use,
PURPOSE FOR TAKING THIS MEDICATION
Is used as a bronchodilator to control and prevent reversible airway obstruction caused by asthma
or COPD.
inhalation: it is used as a quick-relief agent for acute bronchospasm and prevention fo exercise-
induced bronchospasm.
PATIENT EDUCATION WHILE TAKING THIS MEDICATION
Warn the patient about the risk of paradoxical bronchospasm and stop immediately when it
occurs.
Teach and demonstrate with the patient on how to perform oral inhalation correctly.
If there are more prescribed inhalation medication; it is best to wait at least 2 minutes before
repeating the procedure.
Instruct the patient on how to properly wash the inhaler at least once a week.
advise the patient to report any worsening conditions to the health care provider.
PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION: ipratropium bromide
CLASSIFICATION: Bronchodilators; Anicholinergic Allergy, cold and cough remedies, bronchodilators
PROTOTYPE: Ipravent
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
ADULTS AND ADOLECENSAGE 13 AND OLDER: 500mcg via oral nebulizer every 20 minutes for three doses, and as needed; or 8 inhalations of inhalation aerosol every 20 minutes as needed as for 3 hours.
PURPOSE FOR TAKING THIS MEDICATION
Maintenance therapy for reversible airway obstruction due to COPD, including chronic bronchitis and emphysema.
Inhibits cholinergic receptors in bronchial smooth muscle, resulting in decreased concentration of cyclic guanosine monophosphate.
PATIENT EDUCATION WHILE TAKING THIS MEDICATION
Instruct the patient in the proper use of an inhaler, nebulizer, or nasal spray and to take medication as directed. Take missed doses as soon as remembered unless almost time for the next dose; do not double dose. Caution patient not to exceed 12 doses within 24 hours. The patient should notify health care professional if symptoms fo does not improve within 30 minutes after administration of medication or if the condition worsens. Warn the patient that the drug isn’t effective for treating acute episodes of bronchospasm when a rapid response is needed. Teach the patient to use a metered-dose inhaler (MDI) or oral nebulizer correctly.
Date: Student Name: Assigned vSim: Iniials:
J.
Age:
33
M/F:
Female
Code Status:
Diagnosis: ACUTE ASTHMA
Length of Stay:
19 days
Allergies: hay
fever
HCP:
Consults:
Isolaion:
Fall Risk:
Transfer:
IV Type: intraven ous ILocaion : right forearm
Fluid/Rate: 150ml/hr
Criical Labs: Other Services:
Consults Needed:
Why is your paient in the hospital (Answer in your own words and include the History of present Illness)?: The paient was rushed into the emergency due to an Acute Asthma atack; the paient was experiencing shortness of breath, diiculty breathing under respiratory distress, and was not able to speak or form simple phrased sentences.
Health History/Comorbiies (that relate to this hospitalizaion): The Paient was diagnose with Acute Asthma since childhood; paient was experiencing inefecive breathing, anxiety and inefecive airway clearance.
Shit Goals/ Paient Educaion Needs:
1 and review the acion
and purpose of each medicaion
that is prescribed with the -
pateient.
2.. instruct the patient how to avoid any asthma triggers such as smoking, air pollutants, allergens, or other environmental variations.
3. educate the paient on knowing the warning signs and symptoms of an asthma atack and the importance of early treatment, let the paient know
what to do during an emergency crisis related to an asthma atack
4. teach and demonstrate with the paient on how to properly administer medicaions for home management.
Path to Discharge:
When the Paient’s maintains opimal breathing patern.
Clinical Worksheet
Alerts: What are you on alert for with this paient? (Signs & Symptoms)
1. Dyspnea; bronchospasm
2. Abnormal breathing patern (rate, rhythm, depth)
3. Adveniious breath sounds such as wheezing
What Assessments will focus on for this paient? (How will I idenify the above signs &Symptoms?)
1. Assess respiratory rate, rhythm, and depth
2. use pulse oximetry to monitor oxygen saturation
2. Auscultate both lungs for adventitious breaths sounds
List Complicaions may occur related to dx, procedure, comorbidiies:
1. The patient might experience anxiety of not being able to get enough oxygen or respiratory distress
2. The patient was unable to take oral medication due to the tightening of the bronchioles related to asthma
3**. Deficient knowledge; the patient is unaware of emergency medications to administer during an asthma attack.**
What nursing or medical intervenions may prevent the above Alert or complicaions?
1. Continuous monitoring of vital signs
2. Provide medication administration prior to the provider’s order or as needed
3. manage patient’s airway and ventilation such as providing humidified oxygen as needed
- provide emotional support and calming techniques to reduce the patient’s anxiety.
Management of Care: What needs to be done for this Patient Today?
1. Attached pulse ECG and NIBP for continuous assessment of vitals along with heart rate, blood pressure, temp, respirations, and pulse Assess patients vitals along with respiratory status and
2. asses respirations and. auscultated the lungs to distinguish any abnormal lung sounds.
3. monitor pulse oximetry to monitor oxygen saturation, and attach an oxygen mask with humidified oxygen to maintain pulse oximetry about 90% or higher.
4. Administer medication order of albuterol 5mg and ipratropium 500mcg In the nebulizer as providers order. Also, administer methylprednisone 100mg in IV slowly.
5. Assess the patient I. site for any redness, swelling, inflammation, and bleeding. Check the patient’s vital signs and respiratory assessment if it is stable.
6. Provide patient education; discuss proper medication administration, prevention of
asthma attacks, and the emergency measures.
Prioriies for Managing the Paient’s Care Today
1. Plan and review patient daily activities and lifestyle related to avoiding
the risk of future asthma attacks such as avoiding certain foods,
overexertion of physical activity, and environmental factors such as pollen
2. Make sure the patient is aware of each medication uses and proper
administration as needed or as directed by a provider.
3. Patient education in making sure the patient is aware of the risk and
prevention of having asthma attacks and provide any emergency measures.
4. Explain safety measures on the patient an example is staying calm when
under respiratory distress and teach relaxation techniques to reduce the
anxiety that could lead to hypoxia.
What aspects of the paient care can be Delegated and who can do it? the provider would give and prescribe medications the nurse could administer medications as ordered the patient would be able to administer self-care medication at home or emergency medications
Jennifer Hoffman Worksheet v Sim
Course: maternity and pediatrics nursing (2011)
University: Florida SouthWestern State College
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