Fundamentals Ruth Jacobi Activity PDF

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Docucare assignment for Lippincott...

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Fundamentals: Ruth Jacobi: Administering Oxygen by Nasal Cannula Learning Objectives:  Student will utilize principles of nursing informatics to document a patient care experience.  Student will analyze the effectiveness of the nursing plan of care present in the patient’s electronic health record and update/revise as indicated.  Student will analyze data within the electronic health record to determine priority interventions to implement.  Student will create and document an SBAR communication with the healthcare provider in the electronic health record. Case Overview: Ruth Jacobi is a 62-year old female admitted one day ago with left sided weakness, slurred speech and facial droop. A CT of the head revealed a possible ischemic area in the brain. Mrs. Jacobi has returned to her pre-event level of functioning and is being prepared for discharge. The healthcare provider suspects that Mrs. Jacobi had a TIA. DocuCare Activity/Assignment Prep:  Review the Clinical Decision Support Tool (Green Lippincott Advisor links) provided throughout your patient’s chart: o Stroke o Oxygen Administration o Neurological Assessment o Metoprolol  Taylor, C., Lynn, P., & Bartlett, J. Vital Signs. Fundamentals of nursing: the art and science of person-centered care. Philadelphia, PA.: Wolters Kluwer.  Taylor, C., Lynn, P., & Bartlett, J. Oxygenation and Perfusion. Fundamentals of nursing: the art and science of person-centered care. Philadelphia, PA.: Wolters Kluwer.  Hinkle, J. & Cheever, K. Management of patients with cerebrovascular disorders. Brunner & Suddarth’s textbook of medical-surgical nursing. Philadelphia, Pa.: Wolters Kluwer Health/Lippincott Williams & Wilkins.  Review chart including Patient Information, Notes, Assessments, Orders, MAR, Vital Signs, and Diagnostics

Activities/Assignments Part One: Documentation Activity EST TIME: 15 – 30 MIN You enter Mrs. Jacobi’s room and complete a few focused assessments. You are aware that Mrs. Jacobi is to go home later today, so you leave the room to find the CNA who has taken Mrs. Jacobi’s vital signs. The CNA provides you with the following data: Vitals: Temp 98.2o F oral, HR 88, RR 20, BP 174/98, Sats 92% on room Air © 2020 Wolters Kluwer Health. All Rights Reserved.

You have collected the following data from your focused assessments: Mrs. Jacobi is alert, oriented to person, place, time and situation. She has full muscle strength and movement of all extremities. Her pupils are PERRL and 3mm in diameter. She is cooperative and calm. She states she has a slight headache, which she rates as 3/10. Her heart rate is regular with S1, S2, peripheral pulses are +3 and equal bilaterally. Capillary refill time is less than 3 seconds and her skin is pink, warm, dry with elastic turgor. Her lungs are clear to auscultation in upper lobes bilaterally. Her lower lobes are diminished but clear. She has an occasional non-productive cough. She denies shortness of breath. Assignment 1.1: Document the above data and vital signs in Mrs. Jacobi’s electronic health record. Utilize the Assessment and Vital Sign area of the chart. Part Two: Clinical Judgment Activity EST TIME: 30 - 60 MIN After reviewing Mrs. Jacobi’s chart and the data you have entered, identify the relevant data related to the patient situation. Analyze the data, ask yourself these questions: 

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What information is relevant (Recognizing Cues/Assessing) After reviewing Mrs. Jacobi’s data, her oxygen saturation level should be above 95% to indicate an adequate amount circulating through her blood. Her lower lobes with diminished but clear sounds and occasional non productive cough may also contribute to her low saturation level. What does it make you think? (Analyzing Cues/Diagnosing) This make me to believe she’s has: Inffective airway clearance and inffective breathing pattern R/T inadequate amount of oxyen circulating through the blood to her body AEB dimished but clear lower lobes sounds and occasional non productive cough. Nursing Impaired mobility AEB left sided weakness What do you think should be done? (Prioritize Hypotheses & Generate Solutions/Planning) Notify the provider of my findings and recommend oxygen therapy to get her oxygen saturation level above 95 % and hold off on discharging her for monitoring. Ask the provider for pain medication to help with her headache as well. Which interventions are most appropriate? How should they be accomplished? (Take Action/Implementing) I would raise the head of bed to semi fowler position. Encourage fluid intake and monitor I/O. Listen to lungs sounds Q2 hr. Encourage the client to walk down the hallway at least once during my shift. Assess her mobility given she has left sided weakness.

Assignment 2.1: Document the answers to the above questions in the Notes section > Nursing Note - Progress Note Assignment 2.2: © 2020 Wolters Kluwer Health. All Rights Reserved.

Use your answers to the questions above to create an SBAR communication with Mrs. Jacobi’s healthcare provider regarding your concerns. Document your SBAR in the Notes > Nursing Notes – Provider Notification S – Hello Dr. Young. My name is Brenda Copeland the nurse taking care of patient Mrs. Jacobi at Banner Health on the CVICU floor. I am concerned about Mrs. Jacobi oxygen saturation because it is 95% at room air. B- Mrs. Jacobi is alert, oriented to person, place, time and situation. She has full muscle strength and movement of all extremities. Her pupils are PERRL and 3mm in diameter. She is cooperative and calm. She states she has a slight headache, which she rates as 3/10. Her heart rate is regular with S1, S2, peripheral pulses are +3 and equal bilaterally. Capillary refill time is less than 3 seconds and her skin is pink, warm, dry with elastic turgor. Her lungs are clear to auscultation in upper lobes bilaterally. Her lower lobes are diminished but clear. She has an occasional non-productive cough. She denies shortness of breath. Her Vitals: Temp 98.2o F oral, HR 88, RR 20, BP 174/98, Sats 92% on room Air A- The problem seems to be respiratory complication. R- I recommend oxygen therapy to get her oxygen saturation above 95 % and hold off on discharging her for monitoring. Also, would like to give pain medication to help with her headache as well.

Assignment 2.3: Review the nursing care plans present in Mrs. Jacobi’s electronic health record. Determine whether these nursing diagnoses can be resolved, or if revisions/edits need to be made. Document your actions in the Nursing Dx > Impaired Transfer ability and Nursing Dx > Impaired physical mobility area of the chart. Impaired Physical mobility R/T left sided weakness AEB Inability to move purposely within the physical environment Goal statement:   

Patient performs physical activity independently or within limits. Patient uses safety measures to minimize potential for injury. Patient demonstrates the use of adaptive devices to increase mobility

Interventions: © 2020 Wolters Kluwer Health. All Rights Reserved.

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Present a safe environment: bed rails up, bed in a down position, important items close by. Promote and facilitate early ambulation when possible. Aid with each initial change: dangling legs, sitting in chair, ambulation. Show the use of mobility device, such as walker. Let the patient accomplish tasks at his or her own pace. Do not hurry the patient. Encourage independent activity as able and safe.

Part Three: Clinical Judgment Activity EST TIME: 60 MIN In response to your SBAR communication with the healthcare provider, you receive the following orders via telephone:     

Continuous Pulse Oximetry while on Oxygen Hold discharge for now Metoprolol 10mg IV now, recheck BP 15 minutes after administration. Call Healthcare Provider if SBP > 140 or DBP > 100 Chest X-ray - A/P view to rule out Respiratory Disease

Assignment 3.1: Enter the orders listed above using the Orders > Add New Non-Medication Order or Orders > Add New Medication Order feature. Complete all areas found within these screens before hitting save. Assignment 3.2: Document the interventions you identify as being a priority for Mrs. Jacobi (Take Action/Implementing). Document these interventions in Mrs. Jacobi’s electronic health record, and document yourself as the nurse. Assess Mrs. Jacobi for changes in respiratory rate and depth. Assess skin and provide skin care to the area covered by the nasal cannula. Reposition patient and promote ambulation. Part Four: Clinical Judgment Activity: EST TIME: 30 MIN – 60 MIN An hour has passed since implementing your interventions with Mrs. Jacobi. You receive the following information regarding Mrs. Jacobi:   

Chest X-ray – small pleural effusions in lower lung fields Oxygen Saturation 96% on 2 LPM Blood Pressure – 155/98 mm/Hg

Assignment 4.1: Decide whether or not Mrs. Jacobi requires an immediate response by the nurse (Analyzing cues & Prioritizing hypotheses). Provide the data and rationale to support your decision in the Notes > Nursing – Event section of the chart. You can document yourself as the nurse. © 2020 Wolters Kluwer Health. All Rights Reserved.

An immediate response is needed by the nurse.  I would contact the provide and inform him that the patient SBP>140 and Chest X-ray showing a small pleural effusions in the lower lung fields. This critical because this can be a sign of CHF, pneumonia or pulmonary embolism.  I would assess the client for pain and level of consciousness. Monitoring the level of pain and LOC can help to determine whether an underlying disease or is developing.  As a nursing intervention, I would make sure the patient HOB is in Semi fowler for the time being to promote lung expansion. Debriefing Questions 1. How did you feel while completing this assignment? Wow. This made me think critically and put everything I’ve learned so far into completing this scenario case. 2. What went well and what did you struggle with during these activities? I feel coming up with the nursing diagnoses went well because I had enough imformation to make a clinical judgement. I struggled with entering the medication orders. The software wasn’t user friendly. 3. What are some of the complications associated with prolonged elevated blood pressures? It can lead HF, CAD, AAA, MI and many more complications. 4. What pathological events could be contributing to Mrs. Jacobi’s respiratory problems? Her age, activity level and lifestyle. 5. In the future, what aspects of Mrs. Jacobi’s care could be delegated to a Licensed Practical Nurse (LPN) or unlicensed assistive personnel (UAP)? UAP can elevate the HOB, give water, help with ambulation.

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