Answered step-by-stepDetail Clinical Significance/Impact It
Answered step-by-stepDetail Clinical Significance/Impact It is Friday morning (Time…Detail Clinical Significance/ImpactIt is Friday morning (Time 0900), and you are working in a busy Emergency Department. History of present illness: You are caring for Richard, a 45-year-old male. He arrived at the emergency department via EMS transport for a fall from the 15 feet. It was a witnessed fall. His neck is immobilized in a C-Collar. He complains of pain. He is afebrile and anxious. Social History Clinical Significance/ImpactSocial History (from Richard) Richard is a rancher. He owns and operates his own ranch. He has ranched for more than 25 years and has never experienced a serious injury. Today he was trying to repair a roof on a building on his property. A recent rain made the roof more slippery than usual and he lost his footing while repairing a section. He is healthy and has never gone to the doctor except for the flu 4 years ago. He enjoys golf and spending time with his wife and 4 daughters. He does not take any prescription medication but does take 81 mg aspirin daily. Detail Medical History Clinical Significance/ImpactMedical History: No significant past medical history. Subjective History Subjective History (from Richard): Richard has worked hard his entire life and started his own company at the age of 20. He does not smoke, drink, or do illicit drugs. His wife is a stay-at-home wife but sometimes helps with the family company. His father died suddenly from a heart attack, and that is why is takes aspirin every day. He takes the following medications:Medication Dose Last dose takenAspirin 81 mg 0800 yesterday Nursing Assessment: What assessment data is important and why? Assessment Detail Clinical Significance/ImpactObjective DataGeneral Appearance: Richard is grimacing and is alert. He is laying supine on the stretcher bed. He complains of severe pain in his neck. He reports he cannot “take a deep breath”. Temp: 36.8°C (98.24°F)BP:153/80 mmHg MAP 93HR: 119 bpm RR: 28SpO2: 95% on RA NEURO: Alert and disoriented to place/time/situation. GCS 15. PERRLA. Anxious.CARDIAC: Mucous membranes are pink. Capillary refill <3 seconds. Apical HR tachycardic. Peripheral pulses palpable and weak x4 at +1. No edema. No murmurRESP: Lung sounds clear in all lobes. Weak cough, low lung volumes.GI: Abdomen flat. Soft, non-tender. NABS x4. Last BM was today. Negative for nausea and vomiting. GU: Due to void. Musculoskeletal: Moves all extremities with no overt deficits. Reports weakness in BLLE legs. Tingling present in left and right leg from hips down to toes. Integumentary: Skin is warm, diaphoretic, and intact. No bruises or wounds noted.Psychosocial: Worried affect, apprehensive. Wife on her way to bedside for support. You receive the following orders from the provider. What is the clinical significance or impact of each?Pan CT scan (full body) Chest radiograph Electrocardiogram (ECG) Arterial Blood Gas analysis The RN receives the following orders from the provider. What is the clinical significance or impact of each?Intravenous access Continuous cardiac monitoring Pulse oximetry Nasal canula Diagnostic Test Results Clinical Significance/ImpactPan CT scan Fracture on C6 with spinal cord involvement. Fracture on anterior rib 4 on the right. No fractures in Thoracic or sacral spine, hips, legs, or arms. Chest radiograph No atelectasis or infection noted. Mild right pleural effusion. Electrocardiogram (ECG) Rate: 119 BPMP and T wave normalPRI: 0.10QRS: 0.08QTI: 0.36 Arterial Blood Gas analysis pH: 7.292PCO2: 42 mmHgHCO3: 21 mEq/LPO2: 50 mmHgO2 saturation: 90% on RABase excess: +1 mEq/L Family Education Clinical Significance/ImpactThe provider informed Richard that he has a cervical spine injury and may possibly go into acute respiratory failure due to where the injury is located. What education is essential to communicate to Richard and his wife about acute respiratory failure with a spinal cord injury? Richard's wife asks, "what does acute respiratory failure have to do with spinal cord injury?" How would you respond? Case Study ContinuedRichard was transferred to ICU for airway management and advanced trauma care. On day 5 he went into respiratory failure and had to be intubated. His ETT was marked at 5 cm and is F. After 2 weeks it was clear he was ventilator dependent and his wife made the decision to proceed with a tracheostomy. He now has a shiley #8 cuffed tracheostomy. He is being transferred to Progressive care step down. You prepare to call report to Boyd, RN. You review Giles' most recent labs and presenting symptoms. He is on SIMV ventilatory care with a peep of 5 and pressure support of 10 with an Fi02 of 50%. BLLE sensation is absent at this point. He is alert and oriented. He can move BL arms, but cannot extend his wrists. His movements are gross in character. He has an indwelling urethral catheter for neurogenic bladder. Vital signs are: 120/80 mmHg, HR 85 bmp, RR 21, temp 98.6 F, and denies pain. He has an 18 g in the right arm. His wife is being escorted to the PCU waiting area. She is involved in care and has been helpful and understanding. . Considering Richard's history, what information is important to include in handover? Practice using the SBAR format. Situation: Background: Assessment: Recommendation: Medication Administration Considerations/Clinical SignificanceWhat medication orders will Boyd anticipate and why? What is the antidote for analgesics overdose? What nursing interventions will Boyd implement and why? Clinical Significance/ImpactObserve PIV catheter site Assess BP and HR every 4 hours. Respiratory assessment Q2 hours Assess pain Monitor telemetry Monitor Sp02 continuously Monitor vital signs Assist patient with ADL's (nutrition, elimination, hydration, personal hygiene). Test your knowledge!What should the nurse perform during "trach care"? True/False: bleeding around a new tracheostomy is normal? True/False: Sutures are used to secure a new tracheostomy? Discharge Instructions Clinical Significance/ ImpactYou are preparing Richard for discharge to a skilled nursing facility where he will perform physical therapy 3 hours a day. He is on the same vent settings: SIMV/10/5/40%. After rehab he will be discharged home with home health and home physical therapy. The following are new or adjusted prescription medications:Medication Dose Last dose takenAspirin 81 mg Q Daily TodayHydrocodone 5 mg Q6 Today at 1200Colace 100 mg Daily Today at 0900 What instructions will be included for him at discharge? NCLEX-style bonus The client is diagnosed with respiratory failure and has a tracheostomy tube on ventilatory support. The client is on ventilator settings: SIMV, PEEP 5, PS 10, and Fi02 50%, with an Sp02 of 99% and RR of 20. The nurse notices the client's trach site is saturated with a small amount of blood tinged, white-yellow mucus. Which action(s) should the nurse perform next? Select all that apply.Answer ChoicesA. The nurse notifies the health care provider about the blood-tinged mucus.B. The nurse gathers an inner cannula to change out with the current one.C. The nurse gathers a Posey trach tie and Koppa sponge dressing.D. The nurse gathers a trach exchange kit one size smaller for the health care provider.E. The nurse requests a chest radiograph to be prescribed by the provider.F. The nurse cleanses the trach site with normal saline and sterile gauze wipes. Reference: Diepenbrock, N.H. (2012). Quick reference to critical care. Philadelphia, PA: Wolters Kluwer. Educational Objective: Tracheostomy care is important for clients on ventilator support. Nurses will be able to mange the care of clients with impaired ventilation and oxygenation.NCLEX topic: Illness management Category of client need: Physiological adaptation Health ScienceScienceNursingNURS 3021HShare
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