NR 305 Week 8 Discussion, Case Study or Share an Experience

NR 305 Week 8 Discussion, Case Study or Share an Experience Please choose one of the patient scenarios below. Next, complete a rapid assessment, and provide a SBAR report to a classmate. Remember to include all concepts of patient safety, standard precautions, and professional standards. 1. You are covering for a coworker who is off the floor for lunch, when you suddenly hear a loud crash coming from a nearby patient room. You quickly run in and discover Mr. Johnson who was admitted yesterday with a diagnosis of cerebral vascular accident (CVA) unconscious on the floor between the bed and the bathroom. 2. You are called to the room of 2-year-old Jonah by his mother who states the child has suddenly started breathing very loudly and does not look right. Upon entering the room, you quickly recognize that the child is in respiratory distress as his lips are cyanotic and the use of accessory muscles is evident. 3. You are in the process of admitting Ashley, a 27-year-old who is 28 weeks pregnant with her first child, to the obstetric unit for complaints of headache, dizziness, and swelling of her lower extremities when she suddenly begins seizing. Week 8 Discussion This week we are demonstrating our rapid assessment skills. Select one of the above scenarios and discuss what you would do, why you would do it (citing best practice) and include an SBAR. I look forward to seeing you in action. Professor Csonka and classmates, At the Purpose of developing the necessary skills required to complete a concise, accurate, and rapid head-to-toe assessment, we will continue to put the pieces together as we strive to build upon what we have learnt in these weeks past pertaining to interviewing, observing, and assessing our patients to gather information (Chamberlain College of Nursing, 2018). Our rapid assessment-the initial encounter with 2-year-old Jonah whose mother has just called us into his room due to the child experiencing what appears to be a respiratory distress, ought to be completed in a minute or less (Chamberlain College of Nursing, 2018). Upon entering Jonah’s hospital room, we are likely to draw the conclusion that he is indeed in a respiratory distress by quickly recognizing that his lips are turning blue and from the fact that he is using his accessory muscles to aid his ability to take in air into his lungs. Our duty at this crucial moment is to apply our nursing skills towards the collection of the necessary data that will enable us to prioritize our tasks and stabilize this client (Chamberlain College of Nursing, 2018). The first thing we ought to do as contemporary nurses tasked with the care of a patient in apparent respiratory distress, and armed with evidence based nursing judgments in our line of duty is to raise the head of the patient’s bed while calling out his name to find out if he’s alert, responsive and then check for the rise and fall of his chest wall at the same time, to ensure that he’s still able to breath on his own even with his use of his accessory muscles. While taking these initial steps to make the patient comfortable, we will also have to delegate someone with the responsibility of getting a set of vital signs to be used as our baseline while paying special attention to this client’s heart rate, blood pressure and pulse oximetry readings, which are very important indicators in this type of health crisis. Also, we will have to delegate someone else to call the rapid assessment team. If Jonah turns out to be alert and able to communicate his distress to us, then, we can find out from him what he feels about his current situation. While he is talking to us, we will pay attention to whether his language and his speech tone is appropriate for a 2-year-old. Next line of action is to open his mouth and check if there are food or secretion impeding his ability to breath well, while also listening to the sounds of his breathing at the same time. If food or foreign object is found lodged in his mouth, there might be the need to take out the object with our fingers. We may have to suction the patient if secretion is found to be blocking his airways. Nevertheless, we will not try to pull out an object in his mouth unless we can clearly see the object. This is to prevent accidentally pushing the object deeper in the throat of the child. We will also perform CPR only if the child has lost consciousness. To perform CPR (if the child is unconscious), move the child and lay him flat on the floor, or flat on his bed (WebMD, 2016). If this initial sweeping assessment of Jonah was able to rule out foreign object in his mouth and he is in respiratory distress-whose early signs and symptoms are: tachycardia, tachypnea hypertension, use of Accessory muscles, decreased levels of consciousness, decreased oxyhemoglobin saturation (SPO2), circum-oral cyanosis, paleness to nailbeds, and complaint of shortness of breath and the late signs and symptoms are: unconsciousness, bradycardia, bradypnea, hypotension, loss of respiration, and generalized cyanosis-the, we will have to place the client on oxygenation based on severity of case or the parameters that the client has clearly met (Workplace Nurses LLC, 2013). According to Workplace Nurses LLC, the available oxygen therapies for clients with severe respiratory distress are: Supplemental Oxygen by: Nasal Canula - effectively delivers up to 55% oxygen. Maximum flow rate is 6 Liters per minute. FIO2 calculation: FIO2 = (Flow Rate (in LPM) * 4) + 21%. Simple Mask - like Nasal canula. Venturi Mask - flow rate and FIO2 determined by venturi device inserted in Oxygen supply line. Non-Rebreather Mask – delivers up to 100% oxygen based upon reservoir in supply line (Workplace Nurses LLC, 2013). The NIH Stroke Scale, a 15-item systematic assessment tool that depicts a quantitative measure of stroke-related neurologic deficit, is widely used to evaluate acuity and predict patient outcome (Jarvis, 2016). Close attention will be paid to the client’s heart rate and rhythm and we expect to place Jonah on a cardiac monitor with pediatric code pads and to start a large bore IV line to deliver fluids and lifesaving medications such as, Racemic epinephrine (nebulizer), Decadron (IV), Glucocorticoids (oral dexamethasone), prednisolone (oral). Budesonide (oral), which helps to decrease subglottal edema by decreasing local inflammation (Schub and Boling, 2016). This is because cardiac arrests occur frequently in children with respiratory failure (Springer, 2016). We will expect to be given additional doctor’s when and after the medical provider is eventually called to report our findings regarding the client’s status. Likely lab. draws to expect are ABG, CBC, and chemistry. A portable CXR is also likely. The patient is also likely to be intubated to access his airways. SBAR Report Situation: Today is Monday, February 19, 2018 and the time now is 0955. My name is Edwin, the nurse taking care of Jonah, a 2-year-old male who experienced a sudden onset severe respiratory distress and has just emerged from a pediatric code blue in stable condition at present. Jonah will be on his way to your unit shortly to continue to be observed and monitored. Background: The patient’s mother called me to his room around 0800 stating that her son was suddenly with an onset of loud breathing and was not feeling alright. Patient was noted with a significant loud sound to breathing, with cyanosis to his lips, and the use of accessory muscles to breath. Pediatric code blue was called, Jonah was diagnosed with Croup and the patient has been stabilized needing him to be transferred to your unit to continue his care. Patient’s Mother will also accompany patient who is to be transported via bed to his new unit. His mother will likely remain with him at his bedside. Assessment: Jonah is laying on his bed, alert, oriented x 4, and responsive with generalized weakness and has a history of Asthma. His current medications are Nebulizers and IV Decadron. He has 2 antecubital 22G peripheral IV lines to bilateral arms (Allnurses, 2008). Jonah has no known allergies and his last vital signs were taken 20 minutes ago and they are as follows: T. 97.2, R, 22, HR, 85, BP, 98/62, So2, 92%, with a Westley Croup Scale of 7. He is on 100% NRB mask. He was given Racemic epi 0.25ml (2.25%) in 3 ml NS via Neb at 0830. Decadron o.6mg/kg/ iv at 0925 and liquid Tylenol 160mg by mouth at 0900. Labs drawn on Jonah are; ABG, which came out normal, CBC with elevated WBC, and a normal Chemistry profile. Portable CXR was ordered, has been performed on the patient with the results however, still pending. All results that are known from Jonah’s diagnostic tests have been communicated back to his primary doctor with no new orders currently received. Recommendation: Patient will benefit from continuous close monitoring in the Pediatric ICU and will require to be properly evaluated by a Pediatrician. He is also very likely to be looked at by a Pediatric Pulmonologist for further monitoring and treatment that he will require while his Mother will also need discharge education on his nebulizers to continue his treatment at home. Patient will also benefit if he’s discharged with skilled nursing pediatric home healthcare assessment, intervention, monitoring, evaluation and instructions on diet, medications, safety precaution, and pain management among others, home healthcare PT and OT, can also evaluate and treat patient for lower and upper extremities weakness and strengthening respectively, RT, to evaluate and treat for respiratory needs and Social consult will likely be required for available community resources for this patient. References: Allnurses, (2008). Pediatric IV's? Allnurses, 2008, Nov. 22. Retrieved from Chamberlain College of Nursing, (2018). NR-305 Week 7: Putting It All Together: Rapid and Focused Assessment of the Hospitalized Client. [Online lesson]. Downers Grove, IL: DeVry Education Group Jarvis, C. (2016). Physical examination & health assessment (7th ed.). Philadelphia, PA: Saunders Schub, T. B. & Boling, B. C., (2016). Croup. CINAHL Nursing Guide, Springer, S. (2016). Pediatric respiratory failure. Practice essentials. Medscape. Retrieved from: WebMD (2016), Choking in Children. WebMD, Nov. 2. Retrieved from