QuestionUNFOLDING Clinical Reasoning Case Study: Perfusion & Ethics…UNFOLDING Clinical Reasoning Case Study: Perfusion & Ethics Simulation I. Data CollectionHistory of Present Problem: Miriam Leary is a 66 year old female with a past medical history of hypertension, type 2 diabetes mellitus, coronary artery disease, non-ST elevated myocardial infarction in 2016 treated with life-long daily aspirin, chronic kidney disease; stage 4 requiring hemodialysis twice a week, former smoker quit in 2017, and depression. Her home medications are listed below. She presented to the emergency room two days ago with reports of increasing shortness of breath, feelings of heart palpitations and lower extremity edema. She was admitted to the medical-telemetry unit for management of care.Home Medications:1. Lisinopril 40mg daily PO2. Furosemide 20mg daily PO3. Aspirin 81mg daily PO4. Sevelamer 800mg TID PO with meals5. Calcium carbonate 500mg chewable daily PO6. Insulin detemir injection 8units BID SubcutaneousPersonal/Social History: Miriam is divorced. She has two adult children, ages 32 and 36. The 36 year old helps to bring her to doctors’ appointments and grocery shopping. She has a housekeeper who comes twice a week to maintain her apartment and clean her laundry. She used to drive herself to the YMCA for open swimming with her friends, but stopped doing this last year because her kidney disease was becoming too overwhelming for her. Her elderly mother, age 89, is still alive and well. She visits Miriam once a week to bring her any prescription refills she needs. Her father passed away at the age of 78 from complications of coronary artery disease. What data from the histories is important & RELEVANT; therefore, it has clinical significance to the nurse? (2b)RELEVANT Data from Present Problem:Clinical Significance:RELEVANT Data from Social History:Clinical Significance:What is the RELATIONSHIP of your client’s past medical history (PMH) and current meds? (2c)(Which medication treats which condition? Draw lines to connect.)PMH:Home Meds:Pharm. Classification:Expected Outcome:184.108.40.206.220.127.116.11.18.104.22.168.One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology, (if applicable), which disease likely developed FIRST that then initiated a “domino effect” in their life? (2c)Circle what PMH problem likely started FIRST.Underline what PMH problem(s) FOLLOWED as domino(s).II. Patient Care Begins: The client is admitted to the medical floorCurrent VS: WILDA Pain Assessment (5th VS):T: (oral) 98.9Words:Denies pain at this time, 0 out of 10 on a numeric scaleP: (regular) 112Intensity:R: (regular) 25Location:BP: 95/60Duration:O2 sat: 92% on 2 L NCAggravate:Alleviate:What VS data is RELEVANT that must be recognized as clinically significant to the nurse? (2b)RELEVANT VS Data:Clinical Significance:Current Physical Assessment:HEIGHT AND WEIGHT5′ 3″ 155 lb (70.5 kg)GENERAL APPEARANCE:Client repositions self in bed frequently. Appears worried.RESP:Breath sounds crackles with equal aeration bilaterally, labored respiratory effort.CARDIAC:Cool, pallor and moist, 3+ pitting lower extremity edema, heart sounds irregular, pulses weak, equal with palpation at radial/pedal/post-tibial landmarksNEURO:Alert & oriented to person, place, and time (x3), but needs frequent reminders to remain in bed due to her current health statusGI:Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrantsGU:Foley catheter in place, urinating 15mL/hr, clear dark amber urineSKIN:Skin integrity intactWhat assessment data is RELEVANT that must be recognized as clinically significant to the nurse? (2a, 2b, 2c)RELEVANT Assessment Data:Clinical Significance:During the admission process, the client verbalizes feelings of emptiness and is worried that she is too much of a burden on her friends and family. She reports to the nurse that she does not enjoy life recently and has been considering changing her resuscitation status to “Do Not Resuscitate” (DNR). She mentions that her quality of life “isn’t like it used to be.”What additional questions should the nurse ask to gather more data about the client’s current condition? (1a, 2b)Pertinent assessment questions The nurse applies the cardiac telemetry leads. Which lead is placed where? (write green, white, brown, black, red in the appropriate anatomical locations) (5b, 6b) The nurse assesses the 6-second cardiac telemetry strip after placing the client on the monitor. (2b)Cardiac Telemetry Strip:Tele #1: Time 0800Interpretation (2b):Tele #1:Clinical Significance (2c):Tele #1: Evidence-based practice treatment options (3a, 2c):Tele #1This rhythm is new for the client. After communicating the dysrhythmia to the provider, the provider writes for a new medication order:Medication MathHeparin IV Infusion: Bolus the client with 60 units/kg and start infusion at 12 units/kg/hr.Available: Heparin sodium 20,000 units in 1,000 mL D5WCalculate the following:1. Heparin bolus dosage: ________________________2. Infusion rate for the IV: ___________________ units/hr3. Infusion rate in mL/hr: ___________________ mL/hrIII. Clinical Reasoning Begins…What is the primary problem that your client is most likely presenting with? (2c)What is the underlying cause/pathophysiology of this concern? (2c)What nursing priority(s) captures the “essence” of your client’s current status and will guide your plan of care? (if more than one-list in order of PRIORITY) (2b, 3c, 3b)What interventions will you initiate based on this priority? (2b)Nursing Interventions:Rationale:Expected Outcome:What body system(s) will you most thoroughly assess based on the primary problem or nursing care priority? (2b)What is the worst possible/most likely complication to anticipate based on the primary problem? (2c, 5a)What nursing assessments will identify this complication EARLY if it develops? (3a, 3b)What nursing interventions will you initiate if this complication develops? (2b, 3a, 3b, 5a)Medical Management: Rationale for Treatment & Expected OutcomesCare Provider Orders:Rationale:Expected Outcome:Full code1. Vital signs every 4 hours2. Bedrest3. NPO4. Maintain O2 saturation >95% on 1-4L NC5. Indwelling foley catheter6. Monitor strict I&O7. Renal specialty consult8. Basal Metabolic Panel (BMP) every 8 hours 1. 2. 3. 4. 5. 6. 7. 8. 1. 2. 3. 4. 5. 6. 7. 8. PRIORITY Setting: Which Orders Do You Implement First and Why? (2b, 2c)Care Provider Orders:Order of Priority:Rationale:22.214.171.124.5.6.Are there any orders you would question at this time? (1b, 2e)Care Provider Order/s:Rationale:Radiology Reports:What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse? (2c)RELEVANT Results:Clinical Significance:Echocardiogram:Ejection fraction 30%Portable chest x-ray:pulmonary congestion consistent with congestive heart failureLab Results: What lab results are RELEVANT that must be recognized as clinically significant to the nurse? (2b, 2c)Basic Metabolic Panel (BMP:)Current:High/Low/WNL?Previous:Sodium 128 mEq/L132 mEq/LPotassium 6.8 mEq/L5.1 mEq/LChloride96 mEq/L97 mEq/LCO2 (Bicarb) 20 mmol/L22 mmol/LAnion Gap15 mEq/L15 mEq/LGlucose 78 mg/dL91 mg/dLCalcium 7.4 mg/dL7.9 mg/dLBUN 49 mg/dL40 mg/dLCreatinine 3.1 mg/dL2.5 mg/dLRELEVANT BMP Lab(s): Clinical Significance:TREND:Improve/Worsening/Stable: Misc. Labs:Current:High/Low/WNL?Previous:Magnesium 1.2 mEq/L1.5 mEq/LGFR 20mL/min22mL/minRELEVANT Lab(s): Clinical Significance:TREND:Improve/Worsening/Stable: Cardiac Labs:Current:High/Low/WNL?Previous:Troponin 0.38 ng/mL0.2 ng/mLCPK total 72 U/L70 U/LCPK-MB 2%1%BNP (B-natriuretic Peptide) 561 ng/L204 ng/LRELEVANT Lab(s): Clinical Significance:TREND:Improve/Worsening/Stable: Lab Planning: Creating a Plan of Care with a PRIORITY Lab (2b, 3a, 3b):Lab:Normal Value:Clinical Significance:Nursing Assessments/Interventions Required:Current Value:Critical Value:IV. Clinical ReasoningClient assessment findings:Does your initial nursing priority or plan of care need to be modified in any way after obtaining these lab results? (3a)What are your current nursing priorities that will determine your plan of care? (2b)You are about to notify the provider about your abnormal assessment and laboratory findings. Which method of communication will you use to communicate these concerns to the provider? (1a)What information will be crucial to include? (1a, 1b, 2e)Write one example of how you would verbalize your concerns to the health care provider (what would you actually say)Thinking conceptually, which concepts best align with your concerns for your client? (i.e. comfort, metabolism, etc.) (2c)Describe how the client’s problems are interrelated (how does one identified problem effect another or lead to another) (2c)V. Evaluation: Evaluate the response of your patient to nursing & medical interventions during your shift. All physician orders have been implemented that are listed under medical management.Two hours later: You are sitting at the nurse’s station documenting your assessments and communication to provider notifications when you hear a high alert alarm on the central telemetry monitor. You observe the alarm and find the following rhythm change for M. Leary on the screen:Cardiac Telemetry Strip:Tele #2: 1030Interpretation (2b):Tele #2:Clinical Significance (2c):Tele #2:Evidence-based practice interventions (2b, 3a, 3b, 5a): List in order of HIGHEST priority to lowestNursing assessment:Current VS: Most Recent:Current WILDA: T: 99.1 oralWords:unable to respond to pain assessmentP: 0130bpmIntensity:R: 026/minLocation:BP: 0/088/56 mmHgDuration:O2 sat: 40%91% on 2L NCAggravate:Alleviate:Current Physical Assessment:GENERAL APPEARANCE:Unresponsive to stimuli. Miriam’s 36 year old son is at the bedside very upset.RESP:No respiratory effortCARDIAC:Cool, diaphoretic, pallor, with mottled lower extremities. No palpable pulse. NEURO:Unable to arouse, unresponsive. Pupils fixed at 1mm.GI:Not applicableGU:Foley catheter remains in place, no urine output for the last 3 hoursSKIN:Cool, mottledWhat clinical data is RELEVANT that must be recognized as clinically significant? (2b, 3a, 3b)RELEVANT VS Data:Clinical Significance:RELEVANT Assessment Data:Clinical Significance:Has the status improved or not as expected to this point? (2c)Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? (3a)Based on your current evaluation, what are your nursing priorities and plan of care? (2b, 3a)A code blue was called for M. Leary and the code team arrived. Describe the method/style of communication that will be used during the code and why. (1a, 1b)What medications do you anticipate being given to your client in this situation? (2c, 3a, 3b)MedicationNormal Dose RangeRationale1. 2. 3. The client’s son is standing outside the room visibly upset and verbalizing that his mother would not want this to happen to her right now. He tells you that she does not want to be resuscitated.How could you respond to this information? (1a, 2d, 2e)What client-specific outcomes would you develop for your client and their family members at this time? (4a)VII. Caring and the “Art” of Nursing (1a, 1b, 2e)1. What is the client’s family member likely experiencing/feeling right now in this situation?2. What can you do to engage yourself with this experience and show that he/she matter to you as a person?Health ScienceScienceNursingNUR 2005Share Question
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