Covid-ED - Keith RN- COVID Part 1 PDF

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Keith RN- COVID Part 1...

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Part I: Emergency Department (ED) Unfolding Reasoning

John Taylor, 68 years old

Primary Concept Infection/Immunity

Interrelated Concepts (In order of emphasis) x Clinical judgment x Communication

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

Covered in Case Study 9 9 9

NCSBN Clinical Judgment Model Step 1: Recognize Cues Step 2: Analyze Cues Step 3: Prioritize Hypotheses Step 4: Generate Solutions Step 5: Take Action Step 6: Evaluate Outcomes

Covered in Case Study 9 9 9 9 9 9

9 9 9 9

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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, ach 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 visibl anious 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:

Age; History; Current symptoms

HIs age is of signficant- He is 68 years old. Past history- He already has type II diabetes and hypertension Current symptoms: headace, runny nose, weakness, achy, hot to touch and sweaty- He now has a nagging cough and is worried about having COVID

RELEVANT Data from Social History:

Clinical Significance:

Location; Activity

Lives in lg metropolitioan area with over 3000 cases of COVID-19 Active in local community- especially his church

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?

The nurse needs to ask the patient if he has been in contact with anyone who has been diagnosed with Covid-19, if he has been traveling to a location that is a “hot spot” for Covid-19 and needs to swab him for the flu to rule out any other presenting illnesses. The nurse needs to chck his VS to determine if he has a fever.

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

He needs to go to a specified waiting area and a mask needs to be put on him and all of his family members since he has a cough and shortness of breath.

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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: Airborne/Droplet

Implementation Components: Negative pressure room, appropriate PPE (N95 respirtor, gown, gloves), no visitiors and clustering care

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: Infectious agent- The infectious agent is COVID-19 virus

2.

Reservoir- Surfaces and other people

3.

Portal of exit- Coughing, aerosols

4.

Mode of transmission- Direct contact (person to person), inhalation

5.

Poral of entry- Mucous membranes

6.

Susceptible host- Any person especially elderly + immunocompromised

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

Yes- he is elderly (68 years) + presents with chronic diseases (type II diabetes and hypertension). PPE protects against the mode of transmission.

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: T: 100.3 F/38.8 C (oral) P: 118 (regular) R: 20 (regular) BP: 164/88 MAP: 113 O2 sat: 92% room air

P-Q-R-S-T Pain Assessment: Provoking/Palliative: moving makes it worse ach Quality: all over Region/Radiation: 5/10 Severity: continuous Timing:

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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:

Clinical Significance:

Temperature; Pulse; BP; O2; Pain

He has a temperature 100.3 orally His pulse is increased at 118 beats per minute His BP is high 164/88 His O2 is low at 92% on room air He has overall pain that is continuous and achy on a scale of 5

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)

PRIORITY Body System: Lungs; Heart

PRIORITY Nursing Assessments: Lungs- nagging cough and shortness of breath- Crackles + wheezing; Sputum culutre Heart- Hypertension- Is he taking his hypterension medications?

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:

General Survey Neurological Respiratory Integumentary

He is anxious and his body appears tense Exhibits generalized weakness Fine dry crackle bilaterally that diminish on inspiraion + expiration; non-productive cough Skin is hot

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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)

Problems:

Priority Problem:

Rationale: Abnormal breath sounds with non-productive cough with fine dry crackles bitlaterraly- Low 02 on room air. Pt reports shortness of breath

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:

Respirations/Oxygen

GOAL of Care: Nursing Interventions: The nurse will apply a nasal cannula to increase the patient’s oxygen saturation.

The pt will improve 02 after administration of oxygen. Rationale: Expected Outcome: This will force more air into the lungs Increase oxygen saturation

Posiiton patient at a 45 degree angle

This will position the patient in a better way to breathe

Increase oxygen saturation

Caring and the Art of Nrsing 6. What is the patient likely experiencing/feeling right now in this situation? What can you do to engage yourself with his paiens experience, and show that they matter to you as a person? (NCLEX: Psychosocial Integrity)

What Patient is Experiencing: The patient is feeling anxious with his body tensed and his pulse rate increased

How to Engage: The nurse should allow the patient to talk about their feelings and express his concerns. The nurse can implement nonpharmalogical techniques to help calm the patient (deep breathing, guided imagery)

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The ED physician assesses John and orders the following: Collaborative Care: Medical Management 7. State the rationale and expected outcomes for the medical plan of care. (NCLEX: Pharm. and Parenteral Therapies) Care Provider Orders: Rationale: Expected Outcome: Contact-Airborne-Droplet To keep patient and other staff safe Establish airborneprecautions droplet precautions

To rule out

Influenza swab

Negative for influenza

COVID-19 swab (only if influenza neg)

To rule out

Chest x-ray

To determine pneumonia or other respitatory issues

Complete blood count (CBC)

To help get a baseline

Positive for COVID Negative for chest xray

To help get a baseline

Metabolic panel

Baseline acquired for CBC and metabolic panel

To look for sepsis

Lactate Nasal cannula titrate to keep O2 sat >92%

To increase oxygen saturation

No increase in lactate

8. Which orders do you implement first? Why? (NCLEX: Management of Care) Care Provider Orders: Order of Priority: Rationale: x Contact-Airborne-Droplet This is most important to ensure safety 1 precautions A swab is important but other orders are more 3 x COVID-19 swab important x Nasal cannula titrate to 2 NC will help increase 02 after safety has been keep O2 sat >92%

established

Interpreting Diagnostic Data The following diagnostic results just posted in the electronic health record: Radiology Reports: What diagnostic results 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/Physiologic Adaptation)

Results: Diffuse bilateral pulmonary infiltrates

Radiology: Chest X-Ray Clinical Significance: These changes are consistent with a viral pneumonia that is a common complication or progression of COVID-19.

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Lab Results:

Normal Range: Current:

Normal Range: Current:

Hematology (CBC) PLTS % % Neuts Lymphs

WBC

HGB

(4.5-11.0 mm 3)

(12-16 g/dL)

(150-450x 103/µl)

(55-70)

3.5

12.8

224

84

% Monos

% Eosin

Bands

(20-40)

(2-8)

(1-4)

(3-5%)

11

0

0

5

Metabolic Panel CO2 AG

Na

K

Cl

Gluc

Ca

BUN

Creat

GFR

135-145 mEq/L

3.5-5.0 mEq/L

101-111 mmol/L

20-29 mmol/L

(7-16 mEq/L)

64-110 mg/dL

8.5-10.2 mg/dL

10-20 mg/dL

0.8-1.2 mg/dL

>60 mL/min

141

3.9

105

16

14

178

8.9

18

1.10

>60

Normal Range: Current:

Misc. Lactate (Ven)

Influenza

COVID-19

Neg

Neg

(0.5-2.2 mmol/L)

Neg

Pos

2.1

What lab results 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/Physiologic Adaptation)

RELEVANT Lab(s): + for COVID-19 Low WBC HIgh Neutrophils Low lymphocytes Low monocytes Low CO2 Glucose

Clinical Significance: Heightened risk of infection Infection Infection Infection Respitatory disress High glucose- stress; medication regimen

Most Recent Vital Signs: Current VS:

Most Recent in ED:

T: 100.6 F/38.8 C (oral) P: 112 (regular) R: 18 (regular) BP: 142/84 MAP: 103 O2 sat: 93% 2 liters n/c

T: 100.3 F/38.8 C (oral) P: 118 (regular) R: 20 (regular) BP: 154/88 MAP: 110 O2 sat: 90-91% room air

RELEVANT VS Data:

Clinical Significance:

TREND:

Temperature Pulse Respirations BP O2 sat

Sign of infection Can assess anxiety level

Upward Downwards Downwards Downwards Upward

142/84 93% on NC Slight improvement in BP and 02 sat

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John is admitted to the general med/surg floor for observation. To ensure a hand-off that will promote safe patient care to the next nurse, communicate a concise SBAR that captures the essence of Johns status and summarizes the excellent care you have provided!

SBAR Handoff to MedSurg Nurse:

Situation: Hi this is Lauren calling about John Taylor, a 68 yr old male

Name/age:

BRIEF summary of primary problem: He came to the ED today complaining headace, runny nose,

weakness, achy, hot to touch and sweaty- He now has a nagging cough and is worried about having COVID

Background: Primary problem/diagnosis:

He has tested positive for COVID-19

RELEVANT past medical history:

He has Diabetes Type II and Hypertension

Assessment: Most recent vital signs:

T: 100.6 F/38.8 C (oral) P: 112 (regular) R: 18 (regular) BP: 142/84 MAP: 103 O2 sat: 93% 2 liters n/c

RELEVANT body system nursing assessment data: Respiratory, Skin

RELEVANT lab values:

Low WBC, high glucose, + for COVID-19, high neutrophils, low CO2

How have you advanced the plan of care? Patient response:

I recognized the signs and symptoms of COVID-19 and placed my patient on precautions. Pt is stable but not improving

INTERPRETATION of current clinical status (stable/unstable/worsening):

Recommendation: Suggestions to advance the plan of care: I recommend an increase in oxygen and administration of fluids

and administration of insulin for elevated glucose

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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?

I felt like I recognized the signs and symptoms of COVID-19 and placed my patient on the proper precautions to keep them safe.

Weaknesses- Interpretation of lab values: I do not feel comfortable interpreting lab values appropriately

What is your plan to make any weakness a strength?

How will you apply what was learned to future patients?

I

I plan to read and learn more about the lab values so I become more familiar with them.

I feel comfortable recongnizing the signs and symptoms of potential COVID-19. I feel comfortable assessing the patient to rule out other things that the patient could have

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