Pharmacology Scenario 4

Pharmacology Scenario 4: Yoa Li

Documentation Assignments

1. Document your initial assessment data of Yao Li, including IV assessment, level of pain, level of sedation, and vital signs.

Patient status - ECG: Sinus bradycardia. Heart rate: 49. Pulse: Present. Blood pressure: 119/70 mm Hg. Respiration: 10. Conscious state: Somnolent. SpO2: 92%. Temp: 99 F (37.5 C)

assessed the patient's consciousness. The patient scores 11 on the Glasgow Coma Scale (GCS).  

assessed the patient's sedation level using the Pasero Sedation Scale. This was reasonable. The patient was somnolent and had minimal or no response to verbal or physical stimulation. On the Pasero Opioid-Induced Sedation Scale, the patient was graded to 4.

Pt unable to answer any questions- pt was sedated upon initial examiniation*

02 nasal cannula 1L was administered and indicated

administered 0.4 mg of naloxone IV to reverse sedation effect

After administration pain was 8/10.

2. Document information related to the patient-controlled analgesia (PCA) including discontinuation.

  • I stopped the patient controlled analgesia immediately after Glascow and Pasero seditation scale were completed as indicated.

3. Document the medication(s) that you administered.

  • I administered 0.4 mg of naloxone via I.V. to reverse the effects of the opiod.
  • I administered 30 mg of ketorolac IV for pain of 8/10

4. Document any additional interventions completed during the scenario.

I elevated the pt HOB to assist with breathing

I put the patient on oxygen to support the low 02 saturation as indicated- 1 Liter until pt stats were above 92 then it was discontinued.

5. Document any phone calls that occurred during the scenario. Include who was contacted and the results of the conversation.

I phoned the provider in order to discuss the patient. His medication orders were updated to include Ketoralac.

6. Document repeat vital signs taken during this scenario.

Patient status - ECG: Sinus bradycardia. Heart rate: 50. Pulse: Present. Blood pressure: 115/65 mm Hg. Respiration: 9. Conscious state: Somnolent. SpO2: 91%. Temp: 99 F (37.1 C)

administered 0.4 mg of naloxone IV.

Patient status - ECG: Sinus bradycardia. Heart rate: 54. Pulse: Present. Blood pressure: 115/65 mm Hg. Respiration: 15. Conscious state: Somnolent. SpO2: 91%. Temp: 99 F (37.1 C)

Patient status - ECG: Sinus rhythm. Heart rate: 86. Pulse: Present. Blood pressure: 123/70 mm Hg. Respiration: 16. Conscious state: Appropriate. SpO2: 91%. Temp: 99 F (37.1 C)

The patient scores 15 on the Glasgow Coma Scale (GCS

On the Pasero Opioid-Induced Sedation Scale, the patient was graded to 1.

Patient status - ECG: Sinus rhythm. Heart rate: 98. Pulse: Present. Blood pressure: 139/79 mm Hg. Respiration: 18. Conscious state: Appropriate. SpO2: 94%. Temp: 99 F (37.1 C)

Pain assesment 8/10

Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 135/77 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C)

administered 30 mg of ketorolac IV.

Patient status - ECG: Sinus rhythm. Heart rate: 93. Pulse: Present. Blood pressure: 134/77 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37 C)

Pain assessment 3/10

Patient status - ECG: Sinus rhythm. Heart rate: 90. Pulse: Present. Blood pressure: 124/71 mm Hg. Respiration: 13. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C)

7. Document the patient education that you provided to Yao Li during this scenario. Include information on medication actions, side effects, and adverse effects.

I educated the patient about the drug ketorolac.

I educated the patient about the excessive use of medication.

I educated the patient on safety and call lights

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