Covid 19-Case Study-Keith RN PDF

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COVID19-Case Study-KeithRN...

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Part I: Emergency Department (ED) SKINNY Reasoning

John Taylor, 68 years old

Primary Concept Infection/Immunity

Interrelated Concepts (In order of emphasis) • Clinical judgment

NCLEX Client Need Categories Safe and Effective Care Environment • Management of Care • Safety and Infection Control Health Promotion and Maintenance Psychosocial Integrity Physiological Integrity • Basic Care and Comfort • Pharmacological and Parenteral Therapies

Covered in Case Study ✓ ✓ ✓

NCSBN Clinical Judgment Model

Covered in Case Study

Step 1: Recognize Cues Step 2: Analyze Cues Step 3: Prioritize Hypotheses

✓ ✓ ✓

Step 4: Generate Solutions Step 5: Take Action Step 6: Evaluate Outcomes

✓ ✓ ✓

✓ ✓

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• •

Reduction of Risk Potential Physiological Adaptation

✓ ✓

Initial Triage Assessment in ED Present Problem: John Taylor is a 68-year-old African-American male with a history of type II diabetes and hypertension who came to the emergency department (ED) triage window because he felt crummy; complaining of a headache, runny nose, feeling more weak, “achy all over” and hot to the touch and sweaty the past two days. When he woke up this morning, he no longer felt hot but began to develop a persistent “nagging cough” that continued to worsen throughout the day. He has difficulty “catching his breath” when he gets up to go the bathroom. John is visibly anxious and asks, “Do I have that killer virus that I hear about on the news?”

Personal/Social History: John lives in a large metropolitan area that has had over three thousand confirmed cases of COVID-19. He has been married to Maxine, his wife of 45 years and is retired police officer and active in his local church. 1. What data from the histories are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential)

RELEVANT Data from Present Problem:

Clinical Significance:

Pti sa68y ear ol dAf r i canAmer i can mal ewi t hahi s t or yoft y peI Idi abet es andhy per t ens i on. C/ Of eel i ngc r ummy ,headac he,r unny nose,f eel i ngweak / “ achyal l ov er ” ,hot t ot het ouc h,ands weat yt hepas tt wo day s .Dev el opeda“ naggi ngc ough” andSOB.Pti sanx i ousabouthowhe i sf eel i ng. Pt ' sagei sar el ev antf ac t oraswel l .

S/ Sofpos s i bl ei nf ec t i on S/ SofCOVI D19 Comor bi di t i ess uc hasHTNandDM Ty peI Ipr es entan i nc r eas edr i s kf orani nf ec t i onorCOVI D19. Adul t sof65y r sofagear eatani nc r eas edr i s kf oran i nf ect i onorCOVI D19.

RELEVANT Data from Social History:

Clinical Significance:

nc r eas edr i s kofCOVI D19duet ol ar gepopul at i onand Ptl i v esi nal ar gemet r opol i t anar ea. I 3, 000c onfi r medcas esofCOVI D19.numberofconfi r medcases. Mar r i edf or45y r s . Suppor ts y s t em t hr oughbot hhi ss pous eandhi sc hur c h. Act i v ei nhi sl oc al c hur c h.

2. What additional clarifying questions does the triage nurse need to ask John to determine if his cluster of physical symptoms are consistent with COVID-19?

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Hav ey oubeenexpos edt oany onewhohas / hadCOVI D19i nt hel as t14day s ? Hav ey out r av el edi nt hel as t14day s ? T ak ec ur r entt emper at ur e. Hast heptl os tt hei rs ens eofs mel l ort ast e ? Doest hec oughpr oduc eanys put um? Doest hepts mok e,hav eas t hma,hi s t or yofot herr es pi r at or yi s s ues ? Hast heptbeenat t endi ngc hur c hs er v i cesandwear i ngpr operPPE/ s oc i al di st anci ngdur i ngt hes e s er v i c es ? Hast heptbeenwear i ngpr operPPE/ s oc i al di s t anc i ngwhi l ei npubl i c ?

3. Based on the clinical data collected, identify what measures need to be immediately implemented using the following clinical pathway.

I ni t i at ec ont ac t ,dr opl et ,orai r bor nepr ecaut i ons .( dependentonhos pi t al pr ot oc ol ) Hav eptandf ami l ymember swearamas kandey epr ot ec t i on. Hav epti nanegat i v epr es s ur er oom,i fav ai l abl e.I fnotav ai l abl e,hav epti ns i ngl er oom wi t hdoorc l os ed. Admi ni s t erCOVI D19t es t i ng. 4. What type of isolation precautions does the nurse need to implement if COVID-19 is suspected? What specific measures must be implemented to prevent transmission?

Type of Isolation: Cont ac t

Implementation Components: Handhy gi ene,gown,gl ov es .

Dr opl et

Handhy gi ene,gown,gl ov es ,ey epr ot ec t i on,ands ur gi cal mas k.

Ai r bor ne

Ptpl ac edi nanegat i v epr es s ur er oom,i fav ai l abl e.I fnotav ai l abl e,hav epti n s i ngl er oom wi t hdoorc l os ed. Handhy gi ene,gown,gl ov es ,ey epr ot ec t i on,andafit t es t edN95mas k / CAPR s y s t em.Donal l PPEi nANTEr oom,i fpos s i bl e,pr i ort oent er i ngpt ’ sr oom. Doffal l PPEPPEi nANTEr oom,i fpos s i bl e,pr i ort oex i t i ngi nt ohal l way .

5. What are the six steps in the chain of infection? Apply what is known about COVID-19 to each step.

Six Steps: 1.

Coronavirus COVID-19: I nf ec t i ousagent :COVI D19

2.

Res er v oi r :I nf ec t edHuman

3.

Por t al ofExi t :Res pi r at or ySec r et i ons

4.

Tr ans mi s s i onMode:Respi r at or yDr opl et s / Cont ac twi t hi nf ec t edhuman

5.

Por t al ofEnt r y :Anymuc ousmembr ane( Ey es ,Nos e,Mout h)

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Sus c ept i bl eHos t :AnyHuman/ Ani mal

6.

6. Is this patient a susceptible host? What step in the chain of infection does proper isolation precautions impact? Why?

ar ge Yes ,t hepti sov er65y r sol dwi t hc omor bi di t i ess uc hasHTNandDM T y peI I .Theptl i v esi nal met r opol i t anar eawi t h3, 000c onfir medc as esofCOVI D19.Thepti sac t i v ei nhi schur c hwhi c h ex pos eshi mt ot hepubl i candt hepot ent i al f orCOVI D19ex pos ur e. Thet r ans mi s s i onmodei st hek eyt opr ev ent i onandt obr eakt hec hai nofi nf ect i on.Wear i ngpr oper PPEands oc i al di st anc i ngar enec es s ar yt opr ev entt hes pr ead.Keepi ngs ur f ac esc l eanandwas hi ng handsof t enpr ev ent st hes pr eadoft hev i r usaswel l .

Patient Care Begins: John is brought back to a room. As the nurse responsible for his care, you collect the following clinical data: Current VS:

P-Q-R-S-T Pain Assessment:

T: 100.3 F/38.8 C (oral) Provoking/Palliative: “moving makes it worse” P: 118 (regular) “achy” Quality: R: 20 (regular) “all over” Region/Radiation: BP: 164/88 MAP: 113 5/10 Severity: O2 sat: 92% room air continuous Timing: 1. What VS data are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential Reduction of Risk Potential/Health Promotion and Maintenance)

RELEVANT VS Data:

T:100. 3F/ 38. 8C ( or al ) P:118( r egul ar ) R:20( r egul ar ) BP:164/ 88 O2sat :92% r oom ai r Pai n:5/ 10

Clinical Significance: Temper at ur eov er100i ndi cat est hes t ar tofani nf ect i on. Hear ti scompens at i ngf ort hedi st r es swi t hi nt hel ungsandf r om apos si bl ei nf ect i on. Al t houghr es pi r at or yr at ei swi t hi nnor mal l i mi t si t ’ sont hehi gherendwhi chi sa conc er ni nr egar dt ol ungf unct i on. BPi sel ev at ed,howev er ,pthashi st or yofHTN.Iwoul ddet er mi nei fpti sonHTN medi cat i onandi fi twast ak enr ec ent l y .I fmedi cat i onhasbeenpr es c r i bedandt ak en, t hi si ssi gni fic antbecaus ei tagai nshowst hehear ti scompens at i ngf ordi st r es swi t hi n t hel ungsandf r om apos si bl ei nf ect i on. O2s at ur at i oni ndi cat esani s suewi t hi nt hel ungs . Pai ni shi ghandneedst obecont r ol l ed.

2. What body system(s) will you assess most thoroughly performing a FOCUSED assessment based on the primary/priority problem? Identify correlating specific nursing assessments. (NCLEX: Reduction of Risk Potential/Physiologic Adaptation) © 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN

PRIORITY Body System: PRIORITY Nursing Assessments: Res pi r at or y As sess ment :Not eanyacc es s or ymus c l eusagewhenbr eat hi ng.Moni t orf or l abor edbr eat hi ng.Not ef oranyc y anos i s . Aus cul t at i on:Not el ungs oundsbot hant er i orandpos t er i or .Li s t enf or di mi ni s hedbr eat hs ounds,wheez i ng,dul l nes s ,r al es ,et c .

Current FOCUSED Nursing Assessment: GENERAL SURVEY: Appears anxious, body tense NEUROLOGICAL: Alert & oriented to person, place, time, and situation (x4), generalized weakness HEENT: Head normocephalic with symmetry of all facial features. Lips, tongue, and oral mucosa pink and moist. RESPIRATORY: Breath sounds fine dry crackles bilat. with diminished aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, non-labored respiratory effort, episodic nonproductive cough CARDIAC: No edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. ABDOMEN: Deferred GU: Deferred INTEGUMENTARY: Skin hot, dry, intact, normal color for ethnicity. Skin integrity intact, skin turgor elastic, no tenting present. 3. What assessment data is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential Reduction of Risk Potential/Health Promotion & Maintenance)

RELEVANT Assessment Data:

Clinical Significance:

GENERALSURVEY:Appear s anx i ous ,bodyt ens e. NEUROLOGI CAL:Gener al i z ed weaknes s. RESPI RATORY:Br eat hs ounds fi nedr ycr ack l esbi l at .wi t h di mi ni s hedaer at i ononi ns pi r at i on andex pi r at i oni nal l l obes ant er i or l y ,pos t er i or l y ,andl at er al l y , nonl abor edr es pi r at or yeffor t , epi s odi cnonpr oduc t i v ec ough.

Ps yc hol ogi cal f ac t or saffec tt heent i r ebody .Thi sc ani nc r eas e hear tr at e,bl oodpr es s ur e,andr es pi r at or yr at es . Fat i guei nc r eas esr i s kf orf al l sandi ndi c at est hebodyi swor ki ng har dagai ns ts omet hi ngl i k eani nf ec t i on. Nonpr oduct i v ec oughhasbeendet er mi nedt obeaS/ Soft he COVI D19v i r us .Dr yc r ac kl esi ndi c at ei nfl ammat i onori nf ec t i on oft hel ungs .Keepi ngptai r wayi st hepr i or i t y .

4. Interpreting clinical data collected, what problems are possible? Which problem is the PRIORITY? Why? (NCSBN: Step 2: Analyze cues/Step 3: Prioritize hypotheses/NCLEX: Management of Care)

Possible Problems:

Priority Problem:

Rationale:

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COVI D19

COVI D19

Pti sov er65y r sol dwi t hcomor bi di t i ess uc hasHTNand DM T y peI I .Di s pl ay sS/ Soft heCOVI D19vi r us. Theptl i v esi nal ar gemet r opol i t anar eawi t h3, 000 c onfir medc as esofCOVI D19.Thepti sac t i v ei nhi s c hur c hwhi c hex poseshi mt ot hepubl i candt hepot ent i al f orCOVI D19ex pos ur e.

Pneumoni a I nfl uenz a Di ffer ent r espi r at or y i l l ness esand/ or di s eas e

5. What nursing priority(ies) and goal will guide how the nurse RESPONDS to formulate a plan of care? (NCSBN: Step 4 Generate solutions/Step 5: Take action/NCLEX: Management of Care)

Nursing PRIORITY:

Mai nt ai nptai r wayandt r eat mentofCOVI D19

GOAL of Care:

I nc r eas er es pi r at or yf unc t i on,dec r eas e SOB,andmai nt ai nptai r way . Rationale: Ens ur esl ungf unc t i onandSOBdoes n’ t wor s en.

Nursing Interventions: Moni t orpt ’ sr es pi r at or yf unc t i on: Br eat hs ounds ,RR

Expected Outcome: I nc r eas edO2.

Moni t orVi t al Si gnsQ4

eas ei nvi t al El ev at edv i t al si ndi c at ewor seni ngoft hept ’ s Decr s i g n s i n d i c a t e s c ondi t i onandwi l l needf ur t her t r eat menti seffect i v e. ev al uat i on/ at t ent i on.

Moni t orI nt ak e/ Out put

Fl ui dscanas si s ti nt r eat i ngt hept ’ s andbui l dupofflui di n t emper at ur e.Toens ur efl ui dr et ent i oni s n’ ta l ungsi s n’ taconc er n. f ac t or .

Pos i t i onptf oreas eofbr eat hi ng andi nc r eas ebr eat hi ngpat t er ns

T oens ur ebr eat hi ngi sac hi ev edwi t heas e. pr ov i desi nc r eas ed El ev at edHOBc ani nc r eas ebr eat hi ng O2i nt ak eandCO2 out put . f unc t i on.

Ptr emai nshy dr at ed

Easei nbr eat hi ng

Pr ov i dec omf or t

Ps y chol ogi cal f act or s heent i r e T oens ur eptc omf or tandt odec r eas es t r es s affectt b o d y . L a c k o f t h e s e andanx i ous nes sptmaybef eel i ng. f act or sal l owst he bodyt oheal mor e effici ent l y .

Caring and the “Art” of Nursing 6. What is the patient likely experiencing/feeling right now in this situation? What can you do to engage yourself with this patient’s experience, and show that they matter to you as a person? (NCLEX: Psychosocial Integrity) © 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN

What Patient is Experiencing: Anx i et y Fear Lonel i nes s

How to Engage: Educ at et heptaboutCOVI D19andt r eat mentpl an. Beopenandhones twhenans wer i ngques t i ons . As kpthowhei sf eel i nganddi s c us showhe’ s f eel i ng. Ens ur epthasaccesst oc ommuni c at i ondev i cess o t hathemayc ont ac thi ss uppor ts y s t em out s i deof t hehospi t al . Ens ur et heptt hathec anc al l f ory ouany t i meoft he da y / ni ghtandt hathe’ snotani nc onv eni ence. Educ at ept ’ sf ami l yaboutCOVI D19andhowt hey c anpr ot ectt hems el v esands uppor tt hei rl ov edone whent heyar edi s c har ged.

Reflect on Your Thinking to Develop Clinical Judgment To develop clinical judgment, reflect on your thinking that was used to complete this case study by answering the following questions: What did you do well in this case study? What weaknesses did this case study identify? © 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN

t r uggl es omet i meswi t hc onfi denc e.Si nc eCOVI DIat t empt edt oi dent i f yanddefineal l t heS/ SofIs 19hi tt heUni t edSt at esi t ’ sr eal l yaffect edmyc l i ni c al COVI D19. per i enc e.Ienj oyr ecei v i ngf eedbac kf r om my Ir emi ndedmy s el ft ous et heABC’ sofnur s i ng. ex c l i ni cal i ns t r uc t or .Thi swayIk nowwhet herornotI ’ m Ir emi ndedmy s el ft ous eempat hywhen ont her i ghtpat hi nr egar dt omyc ar epl ans . dev el opi ngac ar epl anandt omak es ur et o educat et heptandhi sf ami l yaboutCOVI D19. Iat t empt edt oi dent i f yt hatps y c hol ogi c al f ac t or saffectt heent i r ebodyandi nhi bi tt he bodyf r om heal i ngpr oper l y / effic i ent l y .

What is your plan to make any weakness a strength?

How will you apply what was learned to future patients?

Pr ac t i c econt i nuous l yondi ffer entc as e s t udi es / car epl ansandas kf orf eedbac kf r om mycl i ni c al i ns t r uc t or s .

Iwi l l t ak et hef eedbac kgi v enbymyc l i ni c al i ns t r uct orandappl yi nt hei nper s onaswel l as f ut ur ecas es t udyas s i gnment s .Iwi l l t ak emy under s t andi ngoft heS/ SofCOVI D19andappl yi t whenas s es s i ngmyf ut ur ept s .

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