Medsurg 222 PDF

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65-year-old male who was admitted to a negative pressure room on Med-Surg for COVID precautions.. He has a history of COPD, hypertension, diabetes type II, and a recent myocardial infarction. He is a retired postal worker who lives at home with his wife. He is on Claforan (cefotaxime) 2 g IV q4hr and sliding scale insulin. Initially this cardiologist was concerned about congestive heart failure and Mr. Raymond is receiving Furosemide (Lasix) 20 mg IV twice a day for pulmonary edema. Vital Signs: BP is 145/78, Pulse 89 Respirations 24 and slightly labored, Temperature 100.2 SaO2 94% on 2L nasal cannula. The patient/family is fearing the worst due to COVID-19 Pandemic.

Select appropriate nursing concerns below based upon patient report above:

Physiological Bleeding Death anxiety Disturbed Body Image Esteem Impaired Acute Confusion Impaired Gas Exchange Ineffective breathing pattern Knowledge deficit Pain, Acute Physical Mobility, Impaired Skin Integrity

Tim Jones Room 304 Tim Jones, 82 -year old male patient of Dr. Diggs just arrived this morning from the local nursing home. He was confused upon arrival. During the initial assessment, fresh and various stages of bruise healing were noted to his shoulders, lower back, ribs, and thighs. Admitted to Med-Surg for new onset confusion. Mr. Jones is guarded and has facial grimacing anytime someone reaches toward him or touches him. He does moan when rolled.

You responded correctly to 6 out of 6 evaluations: Category Educational Needs Fall Risk Health change Neurological Pain level Psychological Needs

Your response Increased acuity Increased acuity Increased acuity Increased acuity Increased acuity Increased acuity

Explan Mr. Jones needs reassurance that he is in a safe place and that the staff want to Mr. Jones is 82 years old and confused. New onset bruising as well as various stages of bruise healing noted. Patient is experiencing new onset of confusion. Mr. Jones moans when rolled and has several wounds. Mr. Jones is guarded and grimaces anytime someone reaches toward him.

Virginia Smith Room 305 Virginia Smith, 57-year-old who has elected to have a total mastectomy based on consultation with her surgeon, a total mastectomy removes all breast tissue but leaves all or most of axillary lymph nodes and chest muscles intact. She is also to receive radiation, chemotherapy,

and hormone therapy post operatively. She is with her physician. She is also investigating bone marrow transplantation. She has arrived in preop and about to have surgery this morning. Her husband and two grown children are also with her as she is prepared with gown and head cap awaiting transport to the operating room. She has IV access and has received a small dose of Valium to reduce apprehension. Temperature is 98.3, HR is 87, RR is16, BP is 121/74, PaO2 is 98%.

Listen to nursing report then assign acuity for each category: Assign acuities of "normal" or "increased" based on report Educational Needs Health Change LOC Pain Level Psychological Needs Safety You responded correctly to 4 out of 6 evaluations: Category Educational Needs Health Change LOC

Your response Increased acuity Increased acuity Normal acuity

Ex Status Assessment reports multiple learning needs related to rehab and Status Assessment reports major surgery and rehabilitation needs. Status Assessment reports no evidence of change currently.

Category Pain Level

Your response Increased acuity

No indication of pain at this time.

Ex

Psychological Needs Safety

Normal acuity Increased acuity

Reduced apprehension, but patients is still apprehensive. Status Assessment reports major surgery, post anesthesia, and physical

Wight Goodman Room 306 Wight Goodman, Patient was admitted to the floor last night from the ER for an orbital fracture. He was hit in the left eye by a softball yesterday. Apparently he was pitching, and the batter hit a line drive hitting him in the right side of the face. They applied some ice to his face, and he decided to go to the post game keg party instead of coming to the ER. The patient stated that there was significant swelling, but his vision was fine, and the pain was controlled with beer and 800mg of Motrin. He was unable to sleep later in the evening as the pain became worse, and his vision became more impaired. The Maxillofacial surgeon was consulted, and they will see him this morning. They were not concerned as his intraocular pressure was normal in the ER. There is significant edema and discoloration to the left side of his face, and his left eye is almost completely swollen shut. His visual acuity is diminished, and the whites of his eyes are hemorrhaged. His pain has been well controlled with IV morphine 4 mg, q3 hours. He has a 20g SL to his right hand, that was started in the ER. He has no other health concerns. He’s being admitted for pain control, close observation of his intralocular pressure, and head injury.

Listen to nursing report then assign acuity for each category: Category Educational Needs

Your response Increased acuity

Orbital fracture necessitates patient compliance as they

Fall Risk Health Change

Increased acuity Increased acuity

Visual acuity is altered Patient has had an injury to his left eye, and potential for

Category Pain Level Psychological Needs Neurological

Your response Increased acuity Increased acuity Increased acuity

As a result of sustained injuries No indication of increased acuity GCS is normal at this time

Wight Goodman Patient was admitted to the floor last night from the ER for an orbital fracture. He was hit in the left eye by a softball yesterday. Apparently he was pitching, and the batter hit a line drive hitting him in the right side of the face. They applied some ice to his face, and he decided to go to the post game keg party instead of coming to the ER. The patient stated that there was significant swelling, but his vision was fine, and the pain was controlled with beer and 800mg of Motrin. He was unable to sleep later in the evening as the pain became worse, and his vision became more impaired. The Maxillofacial surgeon was consulted, and they will see him this morning. They were not concerned as his intraocular pressure was normal in the ER. There is significant edema and discoloration to the left side of his face, and his left eye is almost completely swollen shut. His visual acuity is diminished, and the whites of his eyes are hemorrhaged. His pain has been well controlled with IV morphine 4 mg, q3 hours. He has a 20g SL to his right hand, that was started in the ER. He has no other health concerns. He’s being admitted for pain control, close observation of his intralocular pressure, and head injury.

You correctly diagnosed 4 out of 5 options: Physiological Description Acute Pain

Your Response True

Patient has c

Description Bleeding, risk for Impaired Comfort Safety Description Deficient Knowledge Infection, risk For

Your Response True True

Evidence fro Patient requ

Your Response True Orbital fracture necessitates patient com True No indication at this time

Virginia Smith 57-year-old who has elected to have a total mastectomy based on consultation with her surgeon, a total mastectomy removes all breast tissue but leaves all or most of axillary lymph nodes and chest muscles intact. She is also to receive radiation, chemotherapy, and hormone therapy post operatively. She is with her physician. She is also investigating bone marrow transplantation. She has arrived in pre-op and about to have surgery this morning. Her husband and two grown children are also with her as she is prepared with gown and head cap awaiting transport to the operating room. She has IV access and has received a small dose of Valium to reduce apprehension. Temperature is 98.3, HR is 87, RR is16, BP is 121/74, PaO2 is 98%.

You correctly diagnosed 8 out of 10 options: Physiological Description Your Response Bleeding True Patient would be at Risk for Bleeding Impaired Gas Exchange False Status assessment reports no indication Ineffective breathing pattern False Patient would be at Risk for Ineffective Pain, Acute True Status Assessment reports major surge Physical Mobility, Impaired True Status Assessment reports major surge

Description Skin integrity, impaired Safety

Your Response False No indication at this time

Description Your Response Exp Acute Confusion False Status assessment reports no indication of Acute Knowledge Deficit False Status Assessment reports multiple factors assoc Esteem Description Disturbed Body Image Hopelessness

Your Response True Status Assessment reports major body False Status assessment reports no indicatio

Tim Jones 82 -year old male patient of Dr. Diggs just arrived this morning from the local nursing home. He was confused upon arrival. During the initial assessment, fresh and various stages of bruise healing were noted to his shoulders, lower back, ribs, and thighs. Admitted to MedSurg for new onset confusion. Mr. Jones is guarded and has facial grimacing anytime someone reaches toward him or touches him. He does moan when rolled.

You correctly diagnosed 8 out of 8 options: Physiological Description Decisional conflict Defensive coping

Your Response False Scenario does not suppor True Related to fear of abuse

Description Disturbed sleep pattern Ineffective health maintenance Risk for post-traumatic stress syndrome Risk for spiritual distress Safety Description Isolation precautions Risk for injury at home

Your Response False Scenario does not suppo True Patient is unable to prote True Patients with a history of False Scenario does not suppor

Your Response False Scenario does not support this diagnos True Related to presenting with different sta...