Swift River Assignment 1(solved)

Charlie Raymond, 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. Scene 2: Select Nursing Concerns: Scene 3 The next day, he tests positive for COVID 19 and his condition has deteriorated as he is now in respiratory distress. Mr. Raymond weighs 260 lbs. Vital Signs: BP is 92/58, Pulse 102, Respirations 30 and labored, Temperature 101.3, SaO2 91% . He has bilateral lower lobe atelectasis with bronchial/vesicular wheezing. Scene 4 Mr. Raymond continues to deteriorate and becomes confused. In his confusion, he becomes combative and pulls out his IV. He is on a 100% nonrebreather and he keeps pulling his mask off. Just received an order to initiate 20 mg of Furosemide (Lasix) IVP, BID. Scene 5 Order for a foley catheter has been obtained and Lucy Jones, LPN, is there to assist. Both nurses have donned appropriate PPE and have entered the room. Scene 6 UAP reports urinary output of 50 mL over the past three hours. Repeat focused pulmonary assessment reveals profound bilateral atelectasis in the bases and frothy white sputum. Increased Respiratory rate of 32 and labored, peripheral edema +3 in both ankles and JVD. Based on findings, nursing care actions that are most concerning are: Scene 7: Mr. Raymond is stabilized with RRT. Give an SBAR to Hospitalist: Educational need increased fall risk increased Health change increased neuro normal pain level normal patient needs increased Scene 2: Nursing concerns: Physiological FALSE Bleeding False Death anxiety TRUE Disturbed Body Image FALSE Esteem FALSE Impaired Acute Confusion FALSE Impaired Gas Exchange TRUE Ineffective breathing pattern TRUE Knowledge deficit TRUE Pain, Acute FALSE Physical Mobility, Impaired Skin Integrity FALSE Scene 3 Don appropriate PPE. Change to simple O2 face mask per Healthcare provider Perform focused respiratory assessment. Notify respiratory therapist to begin treatment. Notify family to self-isolate for 14 days Scene 4 Reorient patient to setting using therapeutic communication. Obtain a sitter/UAP. Restart the IV. Begin strict I&O. Obtain an order to insert a foley catheter. Scene 5 Use therapeutic communication to explain necessary procedure. Position the patient properly. Create sterile field with foley kit on the bedside table and don sterile gloves. Instruct Lucy to assist in maintaining patient position and field sterility Insert foley catheter according to hospital recommended guidelines,to ensure sterility of catheter. Scene 6 Make sure O2 mask is secure and free of sputum. Ensure patient is in fowlers position. Check the foley catheter to make sure it is not obstructed. Notify Rapid Response team (RRT). Provide initial report and assist RRT. Scene 7 Mr. Raymond, COVID-19 positive, in severe respiratory distress, rapid response called. Patient has a history of COPD, hypertension, diabetes type II, and a recent myocardial infarction. Patient received Furosemide Lasix 20mg, IVP x2, on Claforan Q4, and on sliding scale Insulin. Intubated by RRT, BP: 88/58, P: 110, T: 101.2, SaO2: 94%, ABG's are pending. Foley catheter in place. Recommend patient be transferred to ICU. Accompany your patient to ICU and give report to receiving nurse. Ann Rails 38 years old, c/o back pain, non-significant past medical history. No known allergies (NKA). Vital signs -BP 124/82, Temp 98.2, P 84, RR 22, SaO2 96%. Pain and numbness in legs for one week. Abnormal left leg weakness, gait unsteady, 5/10 on numeric pain scale. Neuro WNL, except leg pain upon movement. Activity as tolerated with assistance. D/C plan- decrease pain and restore normal gait. Regular diet. Dr. Suculo SCENE 2: RN CONSIDERATIONS Scene 3 You enter patient's room. After washing and gloving hands, you then identify yourself and the patient, Ann Rails. You notice she is crying and is expressing fear that she "will always have this pain and numbness" and she doesn't think she can cope. Scene 4 Ms. Rails was medicated with hydrocodone 5 mg PO two hours ago and is now complaining of pain (8/10 pain scale). Scene 5 Ms. Rails shares with you her fear of being discharged home to an abusive husband. Scene 6 Upon entering the room, you find Ms. Rails sleeping. She has received a dose of Hydrocodone for PRN pain 20 minutes ago Scene 7 Ms. Rails states that she has not had a bowel movement (BM) in the past two days. Education needs increased fall risk increased health change increased pain level increased psych needs increased SCENE 2: RN CONSIDERATIONS Physiological: Acute Pain TRUE Bleeding, Risk for FALSE Chronic Pain FALSE Impaired Comfort TRUE Impaired Mobility TRUE Nausea FALSE Safety: Deficient Knowledge TRUE Disturbed Sensory Perception TRUE Fall, Risk for TRUE Grieving FALSE Infection, Risk for FALSE Peripheral Neurovascular Dysfunction TRUE Scene 3 Use therapeutic communication/Active Listening Educate patient regarding patient care Evaluate patient learning Place call light and check bed for safety Document results and findings Scene 4 Wash and glove hands Assess Provide comfort measures Notify doctor Document results and findings Scene 5 Listen to patient concerns Reassure patient of options Notify lead nurse/doctor Contact Social Services Document results Scene 6 Wash and glove hands Visual assessment Do not disturb Verify Call Light/Bed Safety precautions Document results Scene 7 Assess for bowel sounds Encourage fluids/fiber/ambulation Evaluate patient understanding Attain fluids/fiber diet and assisted ambulation Document results CC Chanthavy Chhet, 46 y/o female admitted for dehydration and gastritis. She is accompanied by her uncle who speaks fluent English, but patient speaks little to no English and is a Cambodian native. The uncle suggests that nursing staff address the patient by CC. Family is concerned that she has not been eating or drinking. Her non-verbal communication indicates abdominal discomfort. Vital signs are: T: 99.4 F, 37.4 C, P:92, R:18, PaO2: 98%, BP: 102/82 sitting, BP: 90/64 standing Scene 2: Acuity 3 select appropriate concerns based on info: Scene 3: CC's initial admitting orders include starting an IV D5 ½ NS at 100mL an hour, regular diet is tolerated. Status board indicates that CC's lab work results have been populated. The following labs are: HbG Hemoglobin: 9.1 g/dL (Female: 12 to 16 g/dL or 7.4 to 9.9 mmol/L (SI units) Hematocrit: 35% (Female: 37% to 47% or 0.37 to 0.47 volume fraction (SI units)) WBC: 11,150 mm3 (5000 to 10,000/mm³ or 5 to 10 × 10⁹/L (SI units) Fe: 65 mcg/dl (Female: 60 to 160 mcg/dL or 11 to 29 μmol/L (SI Units)) B12: 300 pg/mL (160-950 pg/mL or 118-701 pmol/L (SI units)) Folate: 4 ng/mL (Greater than 5.4 ng/mL or Greater than 12.2 nmol/L (SI units)) Na: 150 mEq/L (136 to 145 mEq/L or 136 to 145 mmol/L (SI units)) Potassium: 4.8 mEq/L (3.5 to 5.0 mEq/L or 3.5 to 5.0 mmol/L (SI units)) Your initial plan of care is: NEXT SCENARIO: Upon entering the room, you notice the patient is squatting in the corner. You also notice that the IV was removed, and the tubing is on the floor. Blood stains are apparent on her arm and gown. Affect is flat, and she gives limited eye contact. Patient appears to be chattering, but no one is present. You notice that her tray is full, but she only ate the packaged crackers. You relate the following dialogue to the translator: NEXT SCENARIO: You have determined that the patient is hallucinating, delusional, and is not oriented to time and place. She is disorganized in her speech and behavior; the patient is telling you that her Ancestors are warning her that we are trying to poison her. She only eats packaged food. NEXT SCENARIO: Patient resists allowing you to insert the IV. She threatens anyone who goes near her. NEXT SCENARIO: CC has had a psych evaluation, and there is an indication that she needs to be admitted to the psych floor. There are no open psych beds nor open beds in the ICU. You must manage the patient in her existing med-surg room. educational needs Increased fall risk increased health change increased neuro normal pain level increased Scene 2 Physiological: Acute pain TRUE Bleeding risk for False Impaired mobility, risk for True Nausea True Safety: Cultural Competence True Deficient knowledge True Grieving False Impaired Verbal Communication True Peripheral Neurovascular dysfunction False SCENE 3: PLACE IN ORDER Obtain translator Initiate IV Begin fluid and electrolyte replacement Administer IV antibiotics, as ordered Consult with MD about initiating telemetry PLACE IN ORDER: What is going on? We need to stop the bleeding at the IV site with a bandage. Tell me where you are. Who were you talking to in the corner? What were the voices telling you? PLACE IN ORDER: Attempt to establish rapport Notify HCP of your findings, and suggest the need for a stat Psychiatric consult Attempt to re-start the IV Contact dietary to send all food pre-packaged, paper disposable dishes, and no sharps Obtain a sitter, or family member to remain at bedside at all times Remove potential harmful objects from the room PLACE IN ORDER: Delay insertion of the IV Contact HCP and explain patient's response to inserting the IV; request that HCP give a PRN order to manage psychosis Contact CC's uncle to inform him of a change in status Request that the uncle come in to help manage the patient Request that the uncle participates in the scheduled psych evaluation PLACE IN ORDER: Provide one-to-one observation Initiate anti-psychotic medication, as ordered Ensure family member is present Reassess environment Initiate continuous observation and document every 15 minutes John Davis, is a 54 y/o male admitted for surgical resection and biopsy of multiple lesions on his back and shoulders. The patient is fair skinned with multiple moles on his shoulders and anterior and posterior torso. The patient is high risk for basal cell carcinoma and has had mole - mapping. Mr. Davis is very thin and reports an 8 lbs. weight loss over the last four months. He owns a land scape business, works outside, he also enjoys being out on his boat. He had a basil cell carcinoma removed from his forehead four years ago (Mohs micrographic surgery) which has left a large scar. Mr. Davis is concerned about potential scars from these lesions. He denies any other health issues. The patient does not smoke, but drinks 2 beers after work daily and more on the weekends. VS BP 150/89, P 62, R 14, T 98.2. Scene 2 Select Concerns Scene 3 The surgery went well, he had one partial thickness lesion on his shoulder and one of the lesions on his back are full thickness that will require staged closure or a possible skin graft. He has a 4x4 dressing on his right shoulder, two large dressings, and two smaller dressings on his back. His vital signs are stable. He has an IV NS to his left hand @ TKO. He received 2 liters intraoperatively. He was given Fentanyl 100 mg and Zofran 4mg in the PACU. The patient asks if he can go to the bathroom because he needs to void immediately. Scene 4 The patient has been made aware that he has advanced basal cell carcinoma and has a poor prognosis. The largest dressing is saturated with serous sanguineous fluid. The patient is complaining of 8/10 pain from two of the partial thickness incisions on his back (he will need skin graft soon). Patient states the larger dressings on his back that are full thickness do not hurt at all. The patient has an order for dressing changes PRN. The patient is awaiting orders for chemotherapy. VS BP 162/90, P 99, R 20, T 98.9. Scene 5 The nurse's aide reports that the Mr. J did not eat any of his lunch or dinner. The surgeon and oncologist had visited with the patient that morning. When ask the patient about his appetite the patient states that he is nauseated. The SL is occluded. The orders came to initiate Chemotherapy: vismodegib (Erivedge) is 150mg orally daily. The sonidegib (Odomzo) dose is 200 mg orally daily taken on an empty stomach, at least 1 hour before or 2 hours after a meal. Scene 6 The nurse is still concerned about the patient's appetite the next day, 3 days post-op. The patient will be seeing an oncologist before his discharge and the surgeon has stated that he will need to have several more lesions removed ASAP. The patient has learned that his cancer is stage 4 basal cell and has metastasized. He has not been ambulating and has been laying on his back most of the time. When changing the dressings, the nurse notices that the one of wounds on his back appears inflamed and reddened as well. VS BP 150/80, P 82, R 14, T 100.8 Scene 7 The doctor has chosen to pursue a more aggressive chemotherapy agent related to metastasizing cancer and side effects (muscle cramps and gastrointestinal discomfort). The patient will continue chemotherapy after discharge and is being counseled for the placement of a peripherally inserted central catheter (PICC) and why he needs it. The patient will be receiving his chemotherapy from an outpatient infusion clinic. The patient is still not eating and seems complacent in his care. When inquiring about his support system the patient states that running a business does not allow much time for friends or family. Education needs increased fall risk normal health change increased neuro normal pain level normal psych needs normal Scene 2 Nursing Concerns: Psych: Acute pain FALSE chronic pain FALSE Impaired comfort FALSE Nausea FALSE Saftey: Deficient knowledge TRUE grieving FALSE Scene 3 Offer patient a urinal and assist to bedside, if needed Perform post-op assessment to include visual inspection of dressings, vital signs, pain Assist patient to a comfortable position in bed Tell patient not to get out of bed without assistance Ensure side rails are up and call light is within reach Scene 4 Assess the large dressing site (full thickness) Administer pain medication as ordered Assess dressing supply needs and obtain Assess patient's need for emotional support and evaluate effectiveness of pain medication Document color and amount of wound drainage on dressing Scene 5 Restart new IV Administer nausea medicine Assess for contraindications to Chemotherapy Weigh the patient and verify dosage Take VS and provide patient teaching on chemotherapy prior to infusion. Scene 6 Complete full assessment and inspect patient's wounds Apply clean dressing to all wounds Encourage patient to change body position and not lie on wounds Continue to encourage nutrition and fluids Document and inform HCP of wound changes scene 7 Assess patients concerns and understanding plan of care and current treatment Teach patient about the benefits of a picc line with chemotherapeutic agents Make referral to the infusion clinic to verify appointments Consult social services for transportation needs Have patient verbalize understanding of treatment and future needs