Week 4 Case study Covid-19- Skinny Reasoning-Part-1 PDF

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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) x Clinical judgment

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 eak, ach a e and hot to the touch and sweaty the past two days. When he woke up this morning, he no longer felt h b bega  dee a eie aggig cgh ha cied  worsen throughout the day. He has difficulty cachig hi beah he he ge   g he bah. Jh i iib ai ad ak, D I hae ha kie i ha I hea ab  he e?

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:

-Hx of DM and HTN -c/o headache, runny nose, persistent nagging cough, SOB, and hot to the touch -age

Pt is present with the symptoms of covid-19 and infection is one of the leading cause to develop the complications of the DM such as DM Ketoacidosis.

RELEVANT Data from Social History:

Clinical Significance:

3000 confirmed cases in his community Lives with wife (social support) Active in local church

Pt is present with the symptoms of covid-19 and it is significant to know who he got in contact with and his recent travel history.

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?

-Did you travel recently ? -What was your temperature at home? -Did you practise social distancing in the community? -Does your family or any recent contact showing symptoms of covid-19 such as fever, cough ? -Do you have SOB at rest ? -Hx of smoke, asthma or any other respiratory problems, - Immunization hx (flu vaccine)

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

-provide Mask to the patient -Test patient for covid-19 -Use contact and droplet precaution

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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: Contact precaution Droplet precaution

Implementation Components: Gloves, gown, Mask and eye wear protection (goggles)

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: Infection agent : Coronavirus

2.

Reservior: Infected human

3.

Portal of exist: respiratory secretions that are primarily coughed or sneezed out after some incubation

4.

Mode of transmission: contact with the respiratory secretions of an infected person

5.

Portal of entry: mucous membrance in contact with virus (mouth or nose

6.

Susceptible Host: Person showing symptoms such as SOB, cough, and fever

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

Yes, patient is a susceptible host and proper isolation precaution should be initaiated at the level of mode of transmission to break the chain of infection.

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: ig ake i e ach Quality: a e 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:

Patient’s pulse, respiratory rate, O2 saturation and BP. -Pain also

Pt is showing the symptoms of repsiratory distress and proper interventions to keep patent airway is the priority.

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 and skin.

PRIORITY Nursing Assessments: Respiratory and cardiac assessment -Listen to lung sounds anterior and posterior -Listen to heart sounds -Assess skin tugor, mucous membrance (lips), capillary refill

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:

-Fine dry crackles bilaterally with diminished aeration on inspiration and expiration in all lobes -Skin hot

Clinical Significance:

Fine dry crackles sounds is abnormal finding and signifies the complications such as lung infection or pneumonia. Keeping the patent airway is the priority.

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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:

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:

Maintaining patent aiways

Decrease SOB, clear lung sounds and maintaining patent airways by discharge GOAL of Care: Nursing Interventions: Rationale: Expected Outcome: 1. Raise the head of the bed -Promotes lung expansion and improves -improved 2.Administer supplemental perfusion breathing and oxygen with proper humidification. -It helps in preventing respiratory failure SpO2. 3.Encourage to take deep breaths and deliver proper oxygen to the brain and -improved and cough every hour. other vital organs. breathing and 4.Teach effective breathing and -Controlled coughing facilitates moving SpO2 levels coughing techniques. airway secretions. -The patient 5.Increase fluid intake up to 2500 -Fluids may help in promoting secretion coughs mL in 24 hours unless productively and removal and relieve skin dryness. contraindicated by renal or the airway clears cardiac status. with coughing. -The patient has clear airways and a productive

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: COVID-19 is a new disease and alot of people dont have enough information on it. Patient must be anxious and nervous regarding whole situation. Talking, explaining and eductaing can help reduce patient’s anxiety.

How to Engage: -Proper PPE -Therapeutic communication -Educate pateint -Adress pt’s concern and questions -Let them know you are there for them

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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?

Identifying pateint’s problem and priority of care.

About patient’s feeling and how top adress it.

What is your plan to make any weakness a strength?

How will you apply what was learned to future patients?

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