Fluid Overload NextGen SKINNY Reasoning

Fluid Overload NextGen SKINNY Reasoning Anthony Robinson, 67 years old Primary Concept Perfusion/Gas Exchange Interrelated Concepts (In order of emphasis) • Clinical judgment NCLEX Client Need Categories Covered in Case Study NCSBN Clinical Judgment Model Covered in Case Study Safe and Effective Care Environment Step 1: Recognize Cues  • Management of Care  Step 2: Analyze Cues  • Safety and Infection Control Step 3: Prioritize Hypotheses  Health Promotion and Maintenance Step 4: Generate Solutions  Psychosocial Integrity Step 5: Take Action  Physiological Integrity Step 6: Evaluate Outcomes  • Basic Care and Comfort • Pharmacological and Parenteral Therapies • Reduction of Risk Potential  • Physiological Adaptation Present Problem: You are the nurse caring for Anthony Robinson, a 67-year-old African American male patient with a history of heart failure and iron deficiency anemia who was admitted to the medical floor from the emergency department earlier this morning for low hemoglobin. Mr. Robinson’s initial hemoglobin was 6.2 and the primary care provider ordered 2 units of packed red blood cells (PRBC). He received the first unit in the emergency department (ED) over 90 minutes and tolerated well with no change in status. Current Labs (ED): Complete Blood Count (CBC) WBC HGB Hct PLTs 7.5 6.2 34 154 Basic Metabolic Panel (BMP) + Mg Na K Cl CO2 BUN Creat. Gluc Mg 143 3.5 110 26 16 1.1 132 1.8 The second unit was started after he arrived on the floor and is nearly 2/3 finished. You are rounding on your other patients when Mr. Robinson presses his call light and states “I feel like I can’t catch my breath.” When you enter the room, you see Mr. Robinson in bed breathing rapidly and he appears anxious. 1. What data from the present problem is 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 heart failure and iron deficiency anemia hgb- 6.2 hct- 34 Tachypnea (increase RR) -His hgb and hct levels are both low whoch is most likely due to the anemia but could also result from blood loss -Hgb is what transports O2 throuhgout the ody to the tissues, so with the hgb level being so low, it is of concern that there is not enough O2 being distributed throuhoughout the body. - Increase RR could be due to feeling anxious and trying to compensate for the feeling of not being able to catch his breathe Current VS: P-Q-R-S-T Pain Assessment: T: 98.2 F/36.8 C (oral) Provoking/Palliative: P: 102 (regular) Quality: Denies R: 28 (regular) Region/Radiation: BP: 138/89 Severity: O2 sat: 87% RA Timing: