Cameron Daniels - Concepts of Nursing III PDF

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Concepts of Nursing III...

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Cameron Daniels Room 304 Cameron Daniels just turned 18 y/o. She is being admitted from the ER with a diagnosis of pelvic inflammatory disease (PID). She has heavy vaginal discharge with an unpleasant odor. She is complaining of abdominal pain and looks pale. She was seen by OBGYN in the ER and a culture was sent to the lab for Chlamydia and/or Neisseria Gonorrhea. She was a very difficult IV start and has a 23g saline lock (SL) in her right hand. They have ordered a liter bolus of LR, but it is running very slowly and the IV is positional. VS BP 96/58, P 116, R 18, T 101.2 PaO2 92%.

You responded correctly to 2 out of 6 evaluations:

Category Fall Risk Health Change Pain Level Psychological Needs Educational Neurological Status

Your response Normal Normal Normal Normal Normal Normal

Explanation Patient is receiving a liter bolus of LR Related to signs and symptoms Patient verbalized abdominal pain No indication of increased need at this time Needs understanding of PID and risk associated with STD’s No indication of increased need at this time

Cameron Daniels Cameron Daniels just turned 18 y/o. She is being admitted from the ER with a diagnosis of pelvic inflammatory disease (PID). She has heavy vaginal discharge with an unpleasant odor. She is complaining of abdominal pain and looks pale. She was seen by OBGYN in the ER and a culture was sent to the lab for Chlamydia and/or Neisseria Gonorrhea. She was a very difficult IV start and has a 23g saline lock (SL) in her right hand. They have ordered a liter bolus of LR, but it is running very slowly and the IV is positional. VS BP 96/58, P 116, R 18, T 101.2 PaO2 92%.

You correctly diagnosed 1 out of 6 options: Physiological Description AcutePain Impaired mobility Nausea Safety

Description Deficient knowledge Fall, risk for Infection, risk for

Your Response Explanation False Patient verbalized abdominal pain False Patient has an IV False No indication currently

Your Response Explanation False Patient needs education of potential Chlamydia and/or Neisseria Gonorrhea/STD False Patient is receiving a liter bolus of LR False Patient has elevated temperature and fowl smelling vaginal discharge

Scenario 1 Cameron is on the Med-Surg floor and complaining of 9/10 abdominal pain. Her pregnancy test is positive, and the provider is concerned that it may be ectopic and has scheduled an ultrasound. She has an order for Tylenol 1 gm for T > 99.0. The IV barely running and the IV pump keeps alarming occluded. She has only received 500 ml of her Liter bolus. She also has an order for Cefotetan 2 g intravenously IV every 12 hours and doxycycline 100 mg by mouth every 12 hours. VS BP 96/58, P 116, R 18, T 101.2 PaO2 93%.

You correctly ordered 0 out of 5 actions: Is this order correct Your Correct order order Step Explanation 1 Give Tylenol 1g Medication is ordered for elevated temperature and will also treat pain. This makes it the priority as her temp is elevated and her pain is 9/10. 2 Start another IV A new IV is needed to give the fluid bolus. then DC the Never DC a working IV until another is first. established. The first IV may become less positional when she is rehydrated. IV access is the second priority as a fluid bolus and IV antibiotics are ordered. 3 Initiate bolus As ordered by HCP for suspected sepsis. and medications Fluid bolus is needed for blood pressure and to preserve kidney function. 4 Request Medication was ordered for temperature not additional pain for pain relief. The HCP will need to be med order from notified after the nurse leaves the room the HCP 5 Reassess To ensure the temperature is not continuing temperature in to increase and ensure antipyretic was effective. He effects of the Tylenol should be 1hr seen within 1 hour making this the last selection Scenario 2 Patient has become more calm and the nurse is speaking with the Cameron about her diagnosis Once realizing the patient just turned 18 the nurse asks her how many years this relationship has been ongoing and the patient tells her 3 years

You correctly ordered 0 out of 5 actions: Is this order correct

Your Correct order order Step 1 Sit at an eye level with the patient using nonjudgmental therapeutic communication 2 Teach Cameron concerning the complications of PID, STDs, and infectious disease. 3 Evaluate patient understanding of STDs and unprotected sex 4 Contact the charge nurse / law enforcement and inform them about the potential legal issues. 5

Explanation Allows open communication with the patient and establishes trust. Trust must be established first as honesty is imperative in this situation. Patient education is important with new diagnosis. Answering the patient’s questions facilitates trust to receive additional information Evaluating understanding is important after teaching patient for confirmation

Cameron would have only been 15 when the relationship began. It is the legal responsibility of the nurse to be a patient advocate and report any abuse to the charge nurse and proper authorities Document patients’ Documentation is important to statement and prepare a provide evidence that the incident has written report. been reported (date/time/contacts)

Scenario 3 The provider is visiting with Cameron and informs her that her pregnancy test is positive, and they are concerned that it may be ectopic. The patient becomes very upset and admits that she has been also seeing more than one individual as she also had sex with a boy from her high school, "but it was just one time". She asks the nurse not to tell her mother. Later that day Cameron is visited by a young man who brings her flowers. The nurse overhears the patient telling her visitor that she had appendicitis and she will be well soon.

You correctly ordered 1 out of 5 actions: Is this order correct

Your Correct order order Step Explanation 1 Provide emotional support Patient has just found out she is and ask open ended pregnant and will need to know that nonjudgmental questions. she can trust the nurse prior to receiving options for her pregnancy. 2 Assure patient that as an Explaining HIPAA should alleviate patient’s concern of others knowing adult her medical her private medical information, as information is private unless she gives consent well as reminding her that as an adult she has the right to make her for release to other own healthcare choices. This needs individuals to be explained before her choices and responsibilities are explained. 3 Explain to the patient that Communication chain must be she has a sexually explained to the patient when there transmitted disease and is a communicable disease, and the while her patient legal requirement to report the information is private this disease will not violate her privacy. type of disease must be reported to the Department of Health. 4 Stress the importance of Now the patient is ready to receive informing any sexual important direction from the nurse partners of her STD as as all sexual contacts/partners must they may transmit the be notified for their and others disease. protection. To ensure immediate questions are 5 Inform patient that you will set-up a one-on-one answered and a pregnancy consultation is set-up to alleviate with a pregnancy counselor to discuss her patient anxiety but reminds her that she has time to decide who she will pregnancy to include a description of an ectopic trust with this news. pregnancy

Scenario 4 The ultrasound was positive for an ectopic pregnancy and the provider has ordered methotrexate 1.0 mg/kg in two divided doses. Cameron's mother comes to visit and is insisting that she be allowed to talk to the doctor in private. She also asks if she can spend the night. The mother states that they are very religious, and she has invited their pastor to come by to pray for her daughter. The mother has not been made aware of the patient's

diagnosis or social circumstances and is requesting any available information about her daughter.

You correctly ordered 0 out of 5 actions: Is this order correct Your Correc orde t r order Step 2 1 Assess patient, apply a dressing over the IV site to stop the bleeding, and call for additional support to the room. 5 2 Perform a rapid assessment of the patient to ensure she was not injured 1 3 Ask the patient if she was physically assaulted by her father 3 4 Inform the charge nurse to call a code Gray (Security)

4

5

Call the local law enforcement to make a report

Explanation Patient safety, and health is always the first nursing concern.

This is done almost simultaneously as you verify the physical status of all involved. Determine if a physical assault has occurred, as this will quickly verify if the father is a potential risk to others. Joint Commission Standard code for violence in hospital, security response (code colors may change according to the institution). All these actions happen quickly but this action is only done when acts of violence or potential danger persists. It is the obligation for the nurse to report an act of violence and the father left

Your Correc orde t r order

Step

Explanation making the statement he was going to kill someone. This is done immediately after the scene of the incident has been controlled.

Scenario 5 The nurse is preparing to discharge Cameron the next day. The mother and father want to hear the discharge instructions. Cameron asks to be allowed to speak with her parents privately. After a few minutes there are shouts heard from the room with the patient screaming no. The father is seen by the nurse running out of the room and heard stating, "I'm going to kill that bastard". The nurse runs in the room and Cameron is sobbing with the mother at her side. The IV has been pulled out and there is blood on the floor.

You correctly ordered 1 out of 5 actions: Is this order correct Your Correc orde t r order Step 5 1 Assess patient, apply a dressing over the IV site to stop the bleeding, and call for additional support to the room. 1 2 Perform a rapid assessment of the patient to ensure she was not

Explanation Patient safety, and health is always the first nursing concern.

This is done almost simultaneously as you verify the physical status of all involved.

Your Correc orde t r order 2

3

4

4

3

5

Step injured Ask the patient if she was physically assaulted by her father Inform the charge nurse to call a code Gray (Security)

Call the local law enforcement to make a report

Explanation Determine if a physical assault has occurred, as this will quickly verify if the father is a potential risk to others. Joint Commission Standard code for violence in hospital, security response (code colors may change according to the institution). All these actions happen quickly but this action is only done when acts of violence or potential danger persists. It is the obligation for the nurse to report an act of violence and the father left making the statement he was going to kill someone. This is done immediately after the scene of the incident has been controlled....