CLINICAL

REPLACEMENT
PACKET

VSIM CASE: VINCENT BRODY

STUDENT NAME: KARINA RODRIGUEZ

 DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)

▪ Chronic Obstructive Pulmonary Disease (COPD) - A disease that is manifested by limitations in airflow with persistent respiratory symptoms due to
abnormalities in the airways and/or alveolar structures. There are physiologic changes that happen to the airways & alveoli and generally results from significant
exposure to noxious gases or particles. It is also considered to be a treatable disease and it is common.

- Pathophysiology: Changes associated with chronic bronchitis include hypertrophy & hyperplasia of the bronchial mucous glands, increased goblet cells,
ciliary damage, & chronic leukocytic and lymphocytic infiltration of bronchial walls. Widespread inflammation occurs, which leads to airway narrowing & gaining
mucus within the airways—all while producing resistance in the small airways & at its worst, a severe ventilation-perfusion imbalance.

DIAGNOSTIC TESTS
(REASON FOR TEST AND RESULTS)
▪ Complete Blood Count - This test measures for blood cell count including white blood cells, platelets, hemoglobin and hematocrit. Since this pt. has COPD it is critical to monitor
his blood levels, specifically his blood’s oxygen levels since he is at risk for anemia. A CBC with differential may reveal secondary polycythemia as well as an increase in HCT in the
late stages of COPD. The pts. Hb, HCT, platelets & WBCs were all within normal range
▪ Arterial Blood Gas Panel - This test measures for any fluid or electrolyte imbalances in the body, such as potassium, calcium & sodium levels. Since this pt. is currently diagnosed
with COPD, it is best to monitor the pts. electrolyte levels to ensure there are no abnormal values or imbalances.
▪ Chest X-Ray - This test enables the physician to visualize the chest and lungs to determine any other possible abnormalities associated with COPD.
PATIENT INFORMATION
● Name: Vincent Brody
● Age: 67 years old
● Gender: Male
● Married
● Admitted directly from the provider’s office several hours ago for exacerbation of his chronic obstructive pulmonary disease (COPD). Pt. has no known allergies.
● 50-year history of smoking and smokes 2 packs a day.
ANTICIPATED PHYSICAL FINDINGS
▪ Dyspnea
▪ Cyanosis of skin
▪ Abnormal ABG labs showing impaired gas exchange
▪ Decreased oxygen saturation level
▪ Increased HR (tachycardia)
▪ Clubbing of fingers
▪ Use of accessory muscles
▪ Wheezing/Cough
▪ Increased CO2 labs
ANTICIPATED NURSING INTERVENTIONS

1. Monitor/Assess the rate, rhythm, and depth of respiration, chest movement, and use of accessory muscle continuously throughout shift.
2. Administer oxygen therapy to maintain an SPO2 value of 92% and above while also providing pt. education on oxygen therapy.
3. Encourage pt. on seeking smoking cessation programs and how smoking can worsen COPD symptoms.
4. Auscultate lung sounds frequently to monitor for any adventitious breath sounds.
vSim ISBAR ACTIVITY
INTRODUCTION
Your name, position (RN),
unit you are working on
SITUATION
Patient’s name, age, specific reason
for visit
BACKGROUND
Patient’s primary diagnosis, date of
admission, current orders for patient
ASSESSMENT
Current pertinent assessment data
using head to toe approach,
pertinent diagnostics, vital signs
RECOMMENDATION
Any orders or recommendations
you may have for this patient
STUDENT WORKSHEET
My name is Karina Rodriguez and I am a Registered Nurse. I currently work in the Medical
Department. I am calling about Vincent Brody in room 180.
He is a 67-yr-old male who was just admitted directly from the provider’s office several hours ago
for exacerbation of his current COPD diagnosis.
The pt. was admitted on 2/16/2021 at 1200 by his provider. The pts. primary diagnosis is COPD. Pt.
stated that he was experiencing chest pain @ 1240 & the provider was called. A chest x-ray was
ordered & the findings suggest a pneumothorax. He was ordered to be put in continuous ECG
monitoring due to high HR, SPO2 monitoring & have his VS taken every 5 minutes. His SPO2 is to
be maintained above 90%. He has an infusion of potassium chloride in 5% dextrose & a normal
saline IV running at 100 mL/hr & has been given albuterol 2.5 mg in 3mL normal saline via
nebulizer every 20 minutes x 3 doses. He was administered Morphine 2 mg via the right arm prior
to chest tube insertion. The chest tube was inserted @ 1240 & another chest x-ray was taken @
1250. Pt. vitals were stabilized.
Pts. vital signs were taken & BP was 128/76 @ 1230, 135/80 @ 1235 & 143/86 @ 1240. RR was @
21 bpm with audible wheezing @ 1240, increased to 31 bpm @ 1245 & decreased back down to 21
bpm after chest tube insertion. Temperature was 99F & radial pulse was 105 bpm. SPO2 started at
93% & decreased to 87% once pneumothorax was suspected. Skin was assessed & was presented as
normal skin turgor. Pts. lungs were auscultated & had audible wheezing present. Pt. chest pain has
subsided & reports no issues with breathing. Pt. ABGs were abnormal: pH: 7.28, PCO2: 60, PO2:
55, SaO2: 87 & HCT: 0.49. Pt. IV access site was clean, dry & intact as well as chest tube site.
The pt. should remain on oxygen to maintain O2 level of 90%. Pt. ABG labs should continue to be
monitored. The pt. should continue using albuterol via HCP orders. A respiratory assessment should
be performed every hour & report any adventitious sounds or change in respiratory functions. Head-
to-toe assessment should be performed to assess skin integrity every 2 hrs.Pt. should be kept
hydrated & have cold therapy applied to lower slight fever. Pt. should be educated on chest tubes &
chest tube care. Pt. should be encouraged to look into a smoking cessation program due to chronic
smoking history. Pt. should remain in high fowler's position to maintain a patent airway.
 PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION:
Albuterol 5 mg in 3mL normal saline every 20 min PRN x3 doses
CLASSIFICATION:
Therapeutic: bronchodilators
Pharmacologic: adrenergics
PROTOTYPE:
Bronchodilators
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
For Adults and children older than age 12: 2.5 to 5mg every 20 min for 3 doses then 0.15 to 0.3 mg/kg every 1-4 hrs PRN via nebulizer.
5mg in 3 mL in normal saline every 20 min PRN x3 doses is considered to be a safe dose & route.

PURPOSE FOR TAKING THIS MEDICATION

- Treatment or prevention of bronchospasm in asthma or chronic obstructive pulmonary disease (COPD).
- For Inhalation, it is used to prevent exercise-induced bronchospasm.

PATIENT EDUCATION WHILE TAKING THIS MEDICATION

▪ Instruct pt. to take albuterol as directed. If on a scheduled regimen, take a missed dose as soon as remembered, spacing remaining doses at
regular intervals. Do not double dose.
▪ Instruct pt. to contact HCP immediately if shortness of breath is not relieved by medication or is accompanied by diaphoresis, dizziness,
palpitations or chest pain.
▪ Instruct pt. to prime unit with 4 sprays before using & to discard canister after 200 sprays.
▪ Instruct pt. to notify HCP if there is no response to the usual dose or if contents of one canister are used in less than 2 weeks.
▪ Advise pt. to rinse mouth with water after each inhalation dose to minimize dry mouth & clean the water piece with water at least once a week.

Resource: Davis’s Drug Guide

 PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION:
Morphine 2 mg IV/Push
CLASSIFICATION:
Therapeutic: opioid analgesics
Pharmacologic: opioid agonist
PROTOTYPE:
Opioid Analgesics
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
Safe dose and route for adults is 4–10 mg every 3–4 hr. MI– 8–15 mg, for very severe pain additional smaller doses may be given every 3–4 hr . 2 mg
IV/Push is considered to be a safe route & dose for this pt, but is underneath the recommended dose.
PURPOSE FOR TAKING THIS MEDICATION
- Indicated for severe pain.
- Pain severe enough to require daily, around-the-clock long-term opioid treatment and for which alternative treatment options are inadequate.

PATIENT EDUCATION WHILE TAKING THIS MEDICATION

- Instruct pt. how and when to ask for pain medication. Do not stop taking without discussing with HCP; may cause withdrawal symptoms if
discontinued abruptly after prolonged use.
- May cause drowsiness or dizziness. Caution patient to call for assistance when ambulating or smoking and to avoid driving or other activities
requiring alertness until response to medication is known.
- Advise patient that morphine is a drug with known abuse potential. Protect it from theft, and never give to anyone other than the individual for
whom it was prescribed. Store out of sight and reach of children, and in a location not accessible by others.
- Encourage patients who are immobilized or on prolonged bedrest to turn, cough, and breathe deeply every 2 hr to prevent atelectasis.

Resource: Davis’s Drug Guide

 Clinical
Date: 2/16/21 Student Name: Karina Rodriguez Worksheet Assigned vSim: Vincent Brody
Initials: Diagnosis: HCP: Isolation: IV Type: Critical Labs: Other Services:
COPD & N/A N/A
V.B. Pneumothorax N/A ABG Labs
Fall Risk: Location: Right Hand
Age: 67 Length of N/A Dressing clean, dry &
Stay: 1 intact Consults Needed:
M/F: day Consults: Respiratory Therapist
N/A Transfer: Pt. needs Chest X-ray
M Allergies: limited assistance to Fluid/Rate: Potassium Pulmonologist
NKA transfer/ambulate Chloride in 5% Dextrose &
Code Status: Normal Saline w/ rate of
Full Code 100 mL/hr

Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: Pt. has worsening COPD. He was admitted by his
primary doctor due to exacerbations and was sent to the hospital for admission. Pt. has a 50-year smoking history and reports smoking 2 packs a day. Pt. has
reported to have had two exacerbations over the last year.
Health History/Comorbidities (that relate to this hospitalization): Pt. has had a 50-year history of smoking and reports smoking 2 packs a day. As previously stated,
he has had two exacerbations of COPD within the last year.

Shift Goals/ Patient Education Needs:

1. Pt. will have a decreased respiratory rate below 30 breaths/min but not below 12 breaths/min.

2. Pt. & caregiver will be educated on chest tube insertion & how to properly care for chest tubes at home.

3. Pt. will have reduced adventitious lung sounds.

4. Pt. SPO2 will remain at 92% or higher for the remainder of this shift.

Path to Discharge:
Pt. will display decreased signs of respiratory distress, improved airway clearance & maintain an SpO2 of above 92%. The patient will need to practice deep breathing
& coughing exercises. The pt. will display knowledge on how to care for a chest tube insertion. The pts. heart rate should decrease below 120 bpm before discharge.

Path to Death or Injury:

Pt. & caregiver will be educated on oxygen therapy.
Pt. will be educated on deep breathing exercises and its benefits towards respiratory function.
Pt. & caregiver will be educated on chest tube insertion & chest tube care.
Pt. & caregiver will be educated on inhalant medications, such as Albuterol & encouraged smoking cessation programs.
Alerts:
What are you on alert for with this patient? (Signs & Symptoms) Management of Care: What needs to be done for this Patient

1. Hypoxia Today?

2. Dyspnea 1. Assess & monitor vital signs/lab diagnostics every hour.

3. Infection 2. Perform a respiratory assessment every 30 minutes & document any abnormal changes.

3. Administer Albuterol & Morphine as per HCP orders.

What Assessments will focus on for this patient? (How will I
4. Auscultate lung sounds every hour to detect any other adventitious lung sounds.
identify the above signs & symptoms?)
5. Apply a simple oxygen mask and maintain an SPO2 of 92% and higher as ordered.
1. Respiratory Assessment every 30 minutes to assess respiratory rate & lung sounds.
6. Obtain a sputum culture to further determine pt. diagnosis.
2. Inspection of skin integrity every 2 hours to assess change in edema, color &
temperature of skin.
Priorities for Managing the Patient’s Care Today
1. Pt. will have lungs auscultated every 30 minutes to monitor for changes in RR or
3. Pain Assessment to monitor for any sudden chest pain.
adventitious breath sounds.
4. Performing vital signs every 30 minutes to monitor BP & heart rate.
2. Pt. will be encouraged to eat & given fluids to stay hydrated.
List Complications may occur related to dx, procedure, comorbidities:
3. Pt. will have vital signs taken every hour & have lab values monitored for any
abnormalities.
1. Respiratory failure may occur if exacerbations are not properly treated.
4. Pt. will have oxygen placed throughout the shift to maintain SPO2 level of 92% or higher.
2. Infection related to COPD symptoms.
5. Pt. will be educated on chest tubes & how to care for them.
3. Chest tube complications such as infection of stoma or discharge.
6. Pt. will be encouraged to join a smoking cessation program.
What nursing or medical interventions may prevent the above Alert or complications?

1. RN will perform a respiratory assessment every 30 min to monitor for adventitious

What aspects of the patient care can be Delegated and who can do it?
breath sounds or abnormal changes in respiratory rate.
- Taking vital signs periodically & retrieving lab values from the lab for the patient can
2. RN will educate pt. on chest tube insertion & chest tube care.
be delegated to a UAP & LPN.
- Administration of medications can be delegated to an LPN.
3. RN will monitor lab diagnostics & vital signs every hour to assess for abnormal
- Providing fluids and food for the pt. can be delegated to a UAP & LPN.
changes, especially changes in HR & BP.
- UAP can help ambulate the pt.
- Pt. can be taken to get a chest x-ray done by UAP or LPN.
4. RN will continually assess for hypoxemia, fever & dehydration.
NURSING DIAGNOSIS: Ineffective Breathing Pattern

RELATED TO (Include all the reasons for this diagnosis): Ineffective inspiration and expiration occurring with chronic airflow constraints

AS EVIDENCED BY (include all the assessment data to support your diagnosis): Wheezes/crackles on auscultation on both lung fields

GOAL: Patient will maintain an SPO2 of 92% and above for the remainder of the shift.

OUTCOME CRITERIA NURSING ORDERS RATIONALE DOCUMENTATION/

EVALUATION

1. Administer supplemental oxygen, This is to increase the oxygen level and Pt. SPO2 value has returned to 93%
1. The patient will be able achieve an SpO2 value within the and is within normal limits.
as prescribed. Discontinue if SpO2
to maintain airway target range.
level is above the target range, or as
patency and improved
ordered by the physician.
airway clearance within
2-4 hrs. 2. Administer the prescribed Bronchodilators dilate or relax the Pt. has demonstrated clearer
medication, Albuterol. muscles on the airways. Steroids act to breathing sounds after
reduce the inflammation in the lungs. administration of medications.

2. The patient will have a 1. Assess breath sounds and Adventitious sounds may indicate a Pt. shows reduced signs of
reduced respiratory rate adventitious sounds such as wheezes worsening condition or additional respiratory distress, such as
& reduced adventitious and stridor. developing complications such as tachypnea with RR being maintained
lung sounds within 1 hr. pneumonia. Wheezing happens as a at 18 bpm.
result of bronchospasm.

2. Assess for signs of dyspnea (flaring These indicate respiratory distress. Pt. has shown little to no signs of
of nostrils, chest retractions, and use Once the movement of air into and respiratory distress and abnormal
of accessory muscles). out of the lungs becomes challenging, breathing patterns have diminished.
the breathing pattern changes.
 3. The patient will report little to 1. Assess the client’s pain level every Providing a pain assessment every 4 Pt. reports having chest pain of 3 out
no chest pain within the next 2 2-4 hrs to ensure proper hours is always recommended for pts. of 10 within 2-4 hours.
hrs. monitorization. that initially report pain to prevent
further complications from happening.

2. Assist client with splinting the Supporting chest and abdominal Pt. reports minimal pain when
painful area when coughing & deep muscles make coughing more effective coughing or deep breathing.
breathing. and less traumatic.

EVALUATION: Pt. has met all goals. Pt. has been administered simple oxygen and SPO2 has been maintained at 92% and above. Pt. respiratory rate has decreased after
successful insertion of chest tube and administering the ordered medications & supplemental oxygen. Pt. has reported feeling better and shows minimal signs of respiratory
distress, reduced anxiety and reduced chest pain. I would continue monitoring the pt. by assessing respirations & monitoring vital signs every 4 hours while keeping the pt. in
a high-fowler’s position and keeping the pt. hydrated. Pt. should be monitored for any possible allergic reactions to administered medications. I would also perform a pain
assessment every 4 hours to monitor for any possible manifestations of chest pain. Furthermore, I would monitor the chest tube site for any signs of infection and perform
chest tube care as needed.

Nursing Narrative Note:

Include initial head to toe assessment which includes Mentation/LOC, eyes, ears, scalp, skin, neck, heart, lungs, abdomen, pelvic, peripheral, ortho, gait.
Date/Time:

2/16/2021 1230pm: Patient is a 67 year old male who is alert and oriented x3. DX: COPD with suggested pneumothorax and is married. Patient next of kin is his wife,
Katherine Brody. Patient was brought in to ED by the primary doctor. Patient reported feeling short of breath while gardening. Patient has no known allergies. Patient has a
50-year smoking history and reports smoking 2 packs a day. Patient initially appeared to have no signs of respiratory distress, however was presented with wheezing at both
lung bases after auscultation. An infusion of potassium chloride in 5% dextrose and normal saline IV at 100 mL/hr was given at 12pm. Patient is on Albuterol 2.5 mg in 3mL
normal saline nebulized every 20 min PRN x3 doses. at 1230pm, patient reported feeling chest pain and the HCP was immediately contacted. The HCP changed the order to
administer Morphine 2 mg IV/Push to prepare the pt. for chest tube insertion due to possible pneumothorax diagnosis. A chest x-ray was ordered and showed a very large
left-sided pneumothorax present. The mediastinum is normal. Patient is on continuous ECG and SPO2 monitoring and VS taken every 5 min. Patient RR is 21 bpm, HR 104
bpm, Temp. 99F, SPO2 93% and stable and BP is 128/76. Height 5’7”, weight 154 lbs. Patient ABG labs showed low pH of 7.28, PCO2 of 60, PO2 of 55, SaO2 of 87% and HCT of
.49. Patient reported feeling “a lot better” after insertion of chest tube at 1240 and administration of Morphine. Patient showed reduced signs of respiratory distress,
tachycardia and minimal chest pain. IV site access and chest tube site was clean, dry and intact with no drainage present. Lung sounds were auscultated and had audible
wheezing in both lungs. Lungs were inspected and patient showed a barreled chest and clubbed fingers. Mucous membranes show no signs of airway obstruction and skin
shows no skin turgor or cyanosis. Patient stated he takes lung medications at home, but did not specify. Patient SPO2 and VS should be continuously monitored every 2 hours
and report any abnormalities. Patient should be kept hydrated throughout the shift and ABGs should be monitored consistently. Patient should be assisted and encouraged
to ambulate to prevent skin breakdown or atelectasis. Patient should continue ordered medications and be educated on their side effects. Patient should be educated on
chest tube insertion procedure and its associated complications. Karina Rodriguez, RN____________________________________________________________________