NextGen SKINNY Reasoning Atrial Fibrillation/Heart Failure (2/4)

NextGen SKINNY Reasoning Atrial Fibrillation/Heart Failure (2/4) Bill Hill, 71 years old Primary Concept Perfusion Gas Exchange Interrelated Concepts (In order of emphasis) • Clinical judgment • Patient education • Communication • Collaboration 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: Part I: Initial Nursing Assessment Bill Hill is a 71-year old male with a past medical history of benign prostatic hyperplasia (BPH), peripheral vascular disease and myelodysplastic syndrome MDS) two months ago after a bone marrow biopsy. Six weeks ago, Bill was admitted because he had a syncopal episode. He was diagnosed with paroxysmal atrial fibrillation and acute anemia with a Hgb of 6.9 and received a transfusion of one unit of PRBCs. Bill presents to the emergency department today with increasing weakness, fatigue, sinus congestion, fever, and chills the past week. He was around grandchildren with colds two weeks ago. Bill woke up at 6 a.m. today feeling short of breath, and coughing harshly with clear sputum. He had difficulty walking back to bed after getting up to the bathroom. His wife, who is a retired nurse, noted that he was much paler, took his vital signs, which were BP: 96/62, HR: 140 irreg, RR: 24. Bill admits to losing 15 lb (6.8 kg) over the last 2-3 months. Personal/Social History: Mr. Hill is retired and lives at home with his wife in a rural area. His two adult children live out of state. He has been an active, healthy male who enjoys gardening, hunting, and splits wood to heat his home in the winter. Since he has been dealing with changes in his health he has not been able to participate in these activities as much. In the past, he has been employed as a minister who has a strong Christian faith. He denies smoking, alcohol use, and illicit drug use. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: RELEVANT Data from Social History: Clinical Significance: Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 99.6 F/37.6 C (oral) Provoking/Palliative: P: 148 (irreg) Quality: Denies R: 24 (reg) Region/Radiation: BP: 104/60 Severity: O2 sat: 88% room air Timing: