PRIORITY Patient Activity Part III: New Orders/Evaluation/Problem Recognition PDF

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PRIORITY Patient Activity Part III: New Orders/Evaluation/Problem Recognition

Herbie Saunders, 62 years old CHF Exacerbation

David Mueller, 71 years old Below-the-Knee Amputation

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 ✓ Reduction of Risk Potential ✓ Physiological Adaptation

Gladys Parker, 92 years old Weakness and Falls

Percentage of Items from Each Category/Subcategory 17-23% 9-15% 6-12% 6-12% 6-12% 12-18% 9-15% 11-17%

Covered in Case Study ✓ ✓

✓ ✓

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You have completed your initial assessments for each of your three patients. You noticed that Herbie Saunders was experiencing increased shortness of breath due to fluid overload and you appropriately administered his morning medications without delay. You sent pages to each of your patients’ providers with order requests and pertinent updates. Before you begin medication passes for David Mueller and Gladys Parker, you see that you have new orders for your patients.

New Primary Care Provider Orders New Orders Patient #2: David Mueller Medications:

PRN

Diagnostics:

CBC, now

Nursing Orders:

Reinforce surgical dressing, call surgeon if wound continues to drain through

polyethylene glycol, 17g, PO QDAY PRN for constipation docusate/senna 50/8.8 mg PO BID PRN for constipation bisacodyl 10 mg PR QDAY PRN for constipation

Based on these new orders, is there anything you would do differently for your 0900 medication pass?

New Orders Patient #3: Gladys Parker Diagnostics:

Basic metabolic panel + Mg, now

Nursing Orders:

Straight cath once for urine sample collection

Based on these new orders, is there anything you would do differently for your 0900 medication pass?

You have completed your morning medication pass for each of your patients, collected the urine for Ms. Parker, charted your assessments, ensured that labs have been drawn and you are now ready to round on each of your patients again.

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Evaluation of Patient Care Patient #1: Herbie Saunders Current Assessment:

What Do You Notice?

Mr. Saunders is resting comfortably watching TV with the HOB at 30 degrees. His respiratory rate is 20, telemetry shows his HR is 94 and his O2 sats are 98% on the 2 lpm.

He states that his breathing feels easier and it does not feel as difficult for him to talk.

Clinical Significance:

-Patient is resting comfortably and Patient had exacerbation of CHF. is not showing any signs of He was transferred to bed with respiratory distress. head of the bead elevated and administeres 2 lpm via nasal -Respiration rate is now within cannula. Respiration rate and O2 normal limits. O2 sat has sat have improved and patient is increased to 98% on 2 lpm. comfortable. -Patient stated to breath easier and has no difficulty to talk.

What action should be taken with respect to this patient’s use of supplemental oxygen? The skin where the nasal cannula is touching should be assessed for skin breakdown. Patient should be reassessed ever couple of hours to monitor signs of another exacerbation of CHF.

Patient #2: David Mueller Current Assessment: Mr. Mueller is resting comfortably in bed. You assess the dressing to the right stump and note that is relatively unchanged since your initial assessment.

What Do You Notice?

Clinical Significance:

Dressing on his right stump has not been changed since it was last assessed.

Surgical site is stable

Temperature and pain level has lowered.

s/s of possible infection have decreased.

You ask Mr. Muller to rate his pain and he states it is about 2/10. Patient still not had bowel

Patient is still constipated

movement

You recheck his temperature and it is 99.0 F (oral). As it has only been about an hour since you administered PRN bowel medications; the patient has not yet had a bowel movement.

What additional non-pharmacological interventions can you suggest for Mr. Mueller to help avoid constipation? Increase fluid intake, increase fiber intake in his diet, and do active ROM exercises. © 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

Patient #3: Gladys Parker Current Assessment: Ms. Granger is awake and greets you with a smile. She asks you how much longer she has to be hooked up to “this thing” as she points to the bag of IV fluids.

What Do You Notice? Area surrounding IV site is puffy and cool to the touch. Patient stated that area feels uncomfortable.

Clinical Significance: Patient's IV is infiltrated, IV fluids are leaking into the surrounding tissue.

You estimate that there are approximately 300 mls left in the bag and you tell her that it will be about 3 more hours before the infusion is complete. She states, “I was hoping it would be done sooner because this thing in my arm is a little uncomfortable.” Upon closer inspection, you notice that the area immediately surrounding her IV is puffy and cool to the touch.

What do you think happened to her IV? What is the first action you should take? IV catheter when through or came out of the vein. IV fluids needs to be immediately discontinued and IV line removed; another IV line needs to be established in another site.

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Understanding Pathophysiology/Anticipating Complications Patient #1: Herbie Saunders What is the pathophysiology of the priority problem? Priority Problem: Pathophysiology of Problem in OWN Words: Patient is recovering from CHF exacerbation

CHF happens when the heart does not pump blood as well as it should, which can be caused by other conditions such as hypertension or previous MI, which can leave the heart weak or stiff to fill and pump efficiently. CHF can cause s/s such as dspnea, fluid retention, SOB, coughing up pink/white frothy sputum, and cause irregular hearbeat.

What is the worst possible/most likely complication(s) to anticipate based on the primary problem? Worst Possible/Most Likely Complication to Anticipate: Acute Respiratory Distress Nursing Interventions to PREVENT this Complication:

Assessments to Identify Problem EARLY:

Routinely assess vital signs and monitor for s/s of respiratory distress

O2 sat, RR, signs of dyspnea, SOB or restlessness

Nursing Interventions to Rescue:

Provide oxygen to raise O2 sat, raised head of the bed, continuos pulse oximeter monitoring and auscultating lung sounds for fluid retention.

Patient #2: David Mueller What is the pathophysiology of the priority problem? Priority Problem: Pathophysiology of Problem in OWN Words: Risk for infection

Patient is recovering from BKA. Patient has uncontrolled glucose levels which can delay healing. Bacteria can infect surgical site and spread into the body.

What is the worst possible/most likely complication(s) to anticipate based on the primary problem? Worst Possible/Most Likely Complication to Anticipate: Nursing Interventions to PREVENT this Complication: Assess patient's surgical dressing frequently looking for drainage amount, color and odor.

Sepsis

Assessments to Identify Problem EARLY: Check for s/s of infection, which include fever, inflammation, excessive drainage, redness and foul odor.

Nursing Interventions to Rescue: Changing surgical dressing as ordered by provider/surgeon. Assess surgical site and report any changes to health care provider.

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Patient #3: Gladys Parker What is the pathophysiology of the priority problem? Priority Problem: Pathophysiology of Problem in OWN Words: IV infiltration

IV fluid/medication is not circulating within the vein and is accomulating/leaking into surrounding tissue, causing the IV site to swell and become cold to the touch.

What is the worst possible/most likely complication(s) to anticipate based on the primary problem? Worst Possible/Most Likely Complication to Anticipate: Nursing Interventions to PREVENT this Complication: Routinely assess IV site

Tissue necrosis, infection

Assessments to Identify Problem EARLY: Signs of infiltration such as swelling, cold to the touch, and in some instances

Nursing Interventions to Rescue: Discontinue IV infusion and remove IV line. Estimate the amount of OV fluid that was infiltrated and notify healthcare provider. Elevate extremity Perform an assessent of sensation,

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 knowledge gaps did you identify? Identifying priority problems

What did you learn? IV infiltration can be caused by improper placement or dislodgement of the catheter, I always taugh that it was due to a collapsed vein.

I still need to work on my nursing interbention

How will you apply learning caring for future patients? Be observant of the physical, emotional state of the patient in order provide the best possible care taking into consideration the patients reactions/emotions.

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