Respiratory Assessment and Nursing Care for Kenneth Bronson: A Case Study

QUESTION

Kenneth Bronson is a 27-year-old male who was just admitted to the Medical Unit from the Emergency Department. He presented to the Emergency Department two hours ago with chest tightness, difficulty breathing, a productive cough for a week, and fever. Chest x-ray revealed right lower lobe pneumonia. IV was started of normal saline at 75 mL per hour. He is receiving oxygen at 2 L/min per nasal cannula. SpO2 on room air was 90%, which increased to 95% with supplemental oxygen. He had a temp of 102.6°F and was given acetaminophen 1,000 mg in the Emergency Department. Pharmacy just delivered the antibiotics to be given. Document your initial focused respiratory assessment of Kenneth Bronson. 2. Document the assessment changes that occurred before and after the anaphylactic reaction. 3. Document Kenneth Bronson’s new allergy information in his patient record. 4. Identify and document key nursing diagnoses for Kenneth Bronson. 5. Referring to your feedback log, document the nursing care you provided.

ANSWER

Respiratory Assessment and Nursing Care for Kenneth Bronson: A Case Study

Introduction

This essay discusses the initial focused respiratory assessment, assessment changes before and after an anaphylactic reaction, documentation of new allergy information, identification of nursing diagnoses, and the provision of nursing care for Kenneth Bronson, a 27-year-old male admitted to the Medical Unit with pneumonia.

Initial Focused Respiratory Assessment

Upon admission, a comprehensive respiratory assessment was conducted on Kenneth Bronson. The assessment included the following:

a) Respiratory rate: Observed and documented Kenneth’s respiratory rate, noting any signs of increased work of breathing or respiratory distress.

b) Breath sounds: Auscultated lung fields to assess for abnormal breath sounds such as crackles, wheezes, or diminished breath sounds.

c) Oxygen saturation (SpO2): Monitored and recorded SpO2 levels using a pulse oximeter to assess oxygenation status. Noted the initial SpO2 on room air (90%) and the subsequent increase to 95% with supplemental oxygen.

d) Chest pain and tightness: Inquired about the presence and intensity of chest pain or tightness, assessing for any changes in severity.

e) Cough characteristics: Evaluated the nature and quality of Kenneth’s cough, including its productivity, frequency, and any associated symptoms such as sputum color or consistency.

f) Temperature: Measured Kenneth’s temperature to assess for fever and monitor changes in body temperature over time.

Assessment Changes Before and After Anaphylactic Reaction

(Note: It is assumed that the anaphylactic reaction occurred after the administration of antibiotics)

a) Before anaphylactic reaction: Prior to the anaphylactic reaction, Kenneth presented with symptoms consistent with pneumonia, such as chest tightness, difficulty breathing, productive cough, and fever. His oxygen saturation improved with supplemental oxygen, and acetaminophen was administered to manage his elevated temperature.

b) After anaphylactic reaction: Following the anaphylactic reaction, Kenneth experienced a sudden onset of severe respiratory distress, characterized by wheezing, stridor, shortness of breath, and decreased oxygen saturation. He may have displayed signs of systemic allergic response, including hives, angioedema, or hypotension.

Documentation of New Allergy Information

The patient’s record must be updated to reflect Kenneth Bronson’s new allergy information. The documentation should include the following:

a) Allergen: Clearly state the specific antibiotic to which Kenneth had an anaphylactic reaction.

b) Reaction: Describe the allergic reaction in detail, including the signs, symptoms, and severity of the anaphylactic response.

c) Date and time: Record the date and time of the anaphylactic reaction to establish a timeline for future reference and patient safety.

Key Nursing Diagnoses for Kenneth Bronson

Based on the presented case, the following nursing diagnoses may be applicable to Kenneth:

a) Impaired Gas Exchange related to pneumonia and anaphylactic reaction.

b) Ineffective Airway Clearance related to increased sputum production and bronchospasm.

c) Risk for Infection related to compromised immune system and respiratory infection.

d) Acute Pain related to chest tightness and discomfort associated with pneumonia.

e) Anxiety related to difficulty breathing, hospitalization, and potential anaphylactic reactions.

Nursing Care Provided

Referring to the feedback log, the nursing care provided to Kenneth Bronson may include the following:

a) Administering prescribed medications, including antibiotics, analgesics, and bronchodilators.

b) Monitoring vital signs, respiratory rate, oxygen saturation, and temperature at regular intervals.

c) Assisting with activities of daily living, positioning, and mobility to optimize respiratory function.

d) Providing education on self-care measures, medication management, and signs of worsening respiratory distress.

e) Collaborating with the healthcare team to ensure appropriate management of allergic reactions and implementation of preventive measures.

Conclusion

In this case study, the initial focused respiratory assessment of Kenneth Bronson revealed pneumonia symptoms, which were followed by an anaphylactic reaction after antibiotic administration. Proper documentation of the patient’s allergy information, identification of key nursing diagnoses, and the provision of comprehensive nursing care are essential in ensuring optimal management and patient safety.