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John Kelly is a 77-year-old male with a history of osteoarthritis, asthma, early stage dementia, and heart failure who had a right total hip arthroplasty and is post-operative day one. Since surgery he has been on path, resting comfortably and his pain has been controlled with oxycodone 5 mg PO. When the nurse enters the room to do his morning assessment, John is agitated, combative and resistive to staff. He pulled out his Foley urinary catheter, his IV catheter and removed his surgical dressing. His legs are swung over the side rails and is trying to get out of bed. John does not know where he is and oriented to self only. He insists that he is at home and yells out, “You get the hell out of my home or I am going to call the police!” His wife is visibly upset and states that she has never seen him behave like this before. With tears in her eyes she asks you, “What is happening to my husband! Please do something to help him!” Personal/Social History: John is a retired high school math teacher who lives at home with his wife and lives independently. He is active at the senior center where he attends social activities 3-4 times a week. He attends Catholic Mass every Sunday with his wife. He is a nonsmoker and has a glass of wine 2-3 times a week with dinner. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: RELEVANT Data from Social History: Clinical Significance: Patient Care Begins: What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: Current VS: P-Q-R-S-T Pain Assessment: T: 99.1 F/37.3 C (oral) Provoking/Palliative: Pain in his right hip but unable to give details P: 102 (regular) Quality: Tenderness to palpation over incision site R: 18 (regular) Region/Radiation: Right hip BP: 155/65 Severity: Unable to verbalize due to confusion, tenderness to palpation but does not appear to be in acute discomfort based on assessment O2 sat: 95% room air Timing: Unable to verbalize Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved. What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion & Maintenance) RELEVANT Assessment Data: Clinical Significance: Radiology Reports: CT Head What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Results: Clinical Significance: No evidence of acute infarction, intracranial hemorrhage, or masseffect seen. Lab Results: What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Current Assessment: GENERAL APPEARANCE: Agitated, attempting to climb out of bed, pulled out Foley catheter and IV catheter, is not grimacing as if he is in pain but does grimace when incision site is palpated RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort CARDIAC: Pink, warm & dry, slight edema present at incision site, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill, no diaphoresis present NEURO: Alert & oriented to person only, very agitated, unable to maintain focus when asked questions, PERRL, emotionally labile, not easily re-directed, face is symmetrical, speech is clear GI: Abdomen flat, soft/nontender, bowel sounds hypoactive but audible per auscultation in all four quadrants GU: Foley cather pulled out, 400 mL clear, yellow urine in collection bag from the last eight hours SKIN: Incision to right hip intact, patient removed dressing and incision is approximated with sutures, some minor erythema at the site and minor bruising, no warmth, and scant blood tinged drainage noted on the dressing, no odor present. Complete Blood Count (CBC:) Current: High/Low/WNL? Prior to Admission: WBC (4.5-11.0 mm 3) 10.8 6.5 Neutrophil % (42-72) 74 55 Hgb (12-16 g/dL) 10.1 12.8 Platelets (150-450 x103/µl) 225 252 Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved. What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Lab Planning: Creating a Plan of Care with a PRIORITY Lab: (Reduction of Risk Potential/Physiologic Adaptation) Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: Creatinine Value: 1.1 Critical value: Clinical Reasoning Begins… 1. What is the primary problem your patient is most likely presenting? (Management of Care/Physiologic Adaptation) 2. What are the most common signs and symptoms of acute delirium? 3. What signs and symptoms is this patient presenting with that are consistent with acute delirium? 4. What is the underlying cause/pathophysiology of this primary problem? (Management of Care/Physiologic Adaptation) 5. What is a CAM assessment and how will it help assess delirium in this patient? 6. Using the CAM assessment tool, does John meet diagnostic criteria for acute delirium? Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Prior to Admission: Sodium (135-145 mEq/L) 134 136 Potassium (3.5-5.0 mEq/L) 3.6 3.7 Glucose (70-110 mg/dL) 72 114 Creatinine (0.6-1.2 mg/dL) 1.1 0.8 Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved. Collaborative Care: Medical Management (Pharmacologic and Parenteral Therapies) Care Provider Orders: Rationale: Expected Outcome: Discontinue Foley catheter Reinsert IV and saline lock Haloperidol 1-2 mg IV PRN every 4 hours Quetiapine 50 mg PO at bedtime Acetaminophen 500 mg PO every 4 hours PRN pain 12 lead EKG One to one sitter PRIORITY Setting: Which Orders Do You Implement First and Why? (Management of Care) Care Provider Orders: Order of Priority: Rationale: • Quetiapine 50 mg PO at bedtime • 12 lead EKG • One to one sitter • Reinsert IV and saline lock • Haloperidol 1-2 mg IV PRN every 4 hours • Acetaminophen 500 mg PO every 4 hours PRN pain Collaborative Care: Nursing 7. What nursing priority (ies) will guide your plan of care? (if more than one-list in order of PRIORITY) (Management of Care) 8. What interventions will you initiate based on this priority? (Management of Care) Nursing Interventions: Rationale: Expected Outcome: Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved. 9. What body system(s) will you assess most thoroughly based on the primary/priority concern? (Reduction of Risk Potential/Physiologic Adaptation) 10. What is the worst possible/most likely complication to anticipate? (Reduction of Risk Potential/Physiologic Adaptation) 11. What nursing assessments will identify this complication EARLY if it develops? (Reduction of Risk Potential/Physiologic Adaptation) 12. What nursing interventions will you initiate if this complication develops? (Reduction of Risk Potential/Physiologic Adaptation) 13. What psychosocial needs will this patient and/or family likely have that will need to be addressed? (Psychosocial Integrity/Basic Care and Comfort) 14. How can the nurse address these psychosocial needs? (Psychosocial Integrity/Basic Care and Comfort) Evaluation Evaluate the response of your patient to nursing and medical interventions during your shift. All physician orders have been implemented under medical management. Two hours later… Current VS: Most Recent: Current PQRST: T: 98.8 F/37.1 C (oral) T: 99.1 F/37.3 C (oral) Provoking/Palliative: P: 74 (regular) P: 102 (regular) Quality: Sleeping, unable to determine R: 14 (regular) R: 18 (regular) Region/Radiation: BP: 114/64 BP: 155/65 Severity: O2 sat: 93% room air O2 sat: 95% room air Timing: John is resting comfortably and appears to be sleeping in his bed. He received a total of haloperidol 4 mg IV. He has a sitter at the bedside and his wife has gone home to rest. He has not voided since his Foley catheter was pulled out. Before falling asleep an hour ago, he received acetaminophen 500 mg PO for pain at the surgical site. Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved. 1. What data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: RELEVANT Assessment Data: Clinical Significance: 2. Has the status improved or not as expected to this point? (Physiological Adaptation) 3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? (Management of Care) 4. Based on your current evaluation, what are your nursing priorities and plan of care? (Management of Care) Current Assessment: GENERAL APPEARANCE: Calm, body relaxed, no grimacing, appears to be resting comfortably RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort CARDIAC: Pink, warm & dry, slight edema at surgical site, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill, no diaphoresis present NEURO: Sleeping, prior to falling asleep orient to person only, PERRL, facial symmetry, speech was clear, no agitated behavior GI: Abdomen flat, soft/nontender, bowel sounds audible per auscultation in all four quadrants GU: Has not voided since Foley catheter was removed, moderate amount of frank bloody drainage from urethra on to the bed sheets SKIN: Dressing is clean , dry, skin intact Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved. It is now the end of your shift. Effective and concise handoffs are essential to excellent care and, if not done well, can adversely impact the care of this patient. You have done an excellent job to this point; now finish strong and give the following SBAR report to the nurse who will be caring for this patient: (Management of Care) Situation: Name/age: BRIEF summary of primary problem: Day of admission/post-op #: Background: Primary problem/diagnosis: RELEVANT past medical history: RELEVANT background data: Assessment: Most recent vital signs: RELEVANT body system nursing assessment data: RELEVANT lab values: How have you advanced the plan of care? Patient response: INTERPRETATION of current clinical status (stable/unstable/worsening): Recommendation: Suggestions to advance the plan of care: Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved. Education Priorities/Discharge Planning 1. What educational/discharge priorities will be needed to develop a teaching plan for this patient and/or family? (Health Promotion and Maintenance) 2. How can the nurse assess the effectiveness of patient and/or family teaching and discharge instructions? (Health Promotion and Maintenance) Caring and the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation? (Psychosocial Integrity) 2. What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a person? (Psychosocial Integrity) Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment. 1. What did I learn from this scenario? 2. How can I use what has been learned from this scenario to improve patient care in the future?

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