Week 5 Q4 Lab Assignment Scenario: M.J.,

Week 5 Q4 Lab Assignment Scenario: M.J., a 32-year-old, was cooking at home one evening when she accidentally spilled a pot of boiling water. The water spilled over her left hand causing second degree, partial thickness, scalding burns to her fingers, hand, and an area surrounding the left, anterior forearm, approximating 3% total body surface area (TBSA). The scald burns scattered throughout the hand and fingers and there is a small circumferential burn on the forearm. She is healthy and has no medical history, taking daily vitamins with breakfast. She lives in an apartment with her two children, ages six and nine years and is the primary provider for her family. M.J.’s neighbor drove her to the emergency department (ED) of the local city hospital. The emergency team was notified for assessment and care, and after the initial evaluation, she was transferred to a regional hospital with a Burn Center and admitted to a room on the Burn Care floor. The neighbor is currently watching M.J.’s children until her parents arrive from out of town. 1. Evaluate the information in the case and determine the Top 3 Priority concerns or cues. a. Second degree, partial thickness, scalding burns to patient’s fingers, hand and an area surround the left, anterior forearm: b. The burn is approximating 3% total body surface area (TBSA): c. Scald burns scattered throughout the hand and fingers and there is a small circumferential burn on the forearm: 2. Based on the priority concerns, which action(s) should the nurse perform? Select all that apply. A. Complete a head-to-toe assessment. B. Evaluate the pain level using a pain scale. C. Obtain a full set of vital signs. D. Discuss infection control guidelines for the burned client. E. Provide emotional support. F. Encourage the client to verbalize concerns. 3. Which of these factors predispose the client to be transferred to the Burn Care Center? A. Current age. B. The depth of the burn is partial thickness/second degree. C. The burn involves the hands. D. The burn is a scald type of injury. 4. The nurse reviews the agency policy on burn classification. What assumptions can the nurse make, based on this chart about M.J.’s situation? BURN CLASSIFICATIONS Superficial: First Degree Red, dry, painful without blisters, blanches with pressure. Do not include TBSA% estimate. Epithelium injured but intact. Examples: Sunburn or propane flash. Partial Thickness: Second Degree Red, blisters, weepy, shiny, blanches with pressure, moderate to severe pain. Likely to scar. Epithelium and varying layers of dermis are destroyed. Example: Scald Full Thickness: Third Degree Red, dry, white, charred, leathery in appearance. Hair follicle removes easily, diminished pain. High probability of deformity and scarring. Epidermis and dermis are destroyed. Extends to subcutaneous layers, muscle, and bones. Example: Flame A.The burn will remain dry with minimal pain. B. The depth of the burn is into the epithelium and will be painful. C. The burn is considered deep and should not have pain. D. The hair will not grow back. 5. The nurse completes a head-to-toe assessment and documents the findings. Circle or highlight the area on the electronic record that is the highest priority. Name: M.J. Health Care Provider: J. S., MD Code Status: Full Code Age: 32 years Allergies: NKDA VITAL SIGN RECORD Time BP(MAP ) HR RR Sats Pain Level (1-10) Weight Radial Pulses R/L Pedal Pulses R/L Dec. 2 1945 128/80 (96) 95 16 98% Room Air 8 145lbs. (65.9 kg) 3+ 3+ 3+ 3+ 6. The nurse uses a numerical rating scale (1-10) to assess M.J.’s pain. Which other pain assessment tool is the next best method to assess M.J.’s physical pain and psychological distress? A. Visual Analog Scale (VAS). B. Pain Thermometer Scoring. C. Faces Pain Rating Scale. D. Color Analogue Scale. Name: M.J. Health Care Provider: J. S., MD Code Status: Full Code Age: 32 years Allergies: NKDA HEALTH CARE PROVIDER PRESCRIPTIONS Dec. 2 2000 1. Admit to the burn care unit. 2. Routine vital signs; neurovascular/circulatory checks to burned extremity every 1 hour. 3. Activity as tolerated. 4. Regular diet as tolerated; encourage protein. 5. Peripheral IV to the unburned extremity. 6. Elevate burned extremity on two pillows. 7. Complete blood count (CBC), electrolytes, hCG, serum albumin, electrocardiogram (EKG), urinalysis. 8. Consult plastic surgery for preoperative evaluation. 9. Begin cleansing and gentle debridement followed by a sterile non adhesive dressing. 10. Tetanus toxoid intramuscular x 1 stat. 11. Famotidine 20 mg orally twice daily. 12. Ascorbic acid 500 mg orally three times a day. 13. Ringers lactate at 50 mL/hour. 14. Cefazolin 1 gram intravenous every eight hours. 15. Oxycodone/acetaminophen 5/325 mg 1-2 tabs orally every 6 hours as needed for pain. 16. Morphine 1 mg intravenous every 2 hours as needed for breakthrough pain scale rating 1-5. 17. Morphine 2 mg intravenous every 2 hours as needed for breakthrough pain rating 6-10. 7. The nurse develops the plan of care and notes the provider’s prescriptions. In what order should the nurse perform the interventions? ____, ____, ____, ____, ____. A. Insert peripheral IV and begin Ringers lactate infusion. B. Elevate the burned extremity. C. Medicate for pain with oxycodone/acetaminophen. D. Obtain vital signs and perform neurovascular/circulatory assessment. E. Provide tetanus toxoid injection. Several hours have passed, and M.J. has required maximum pain medication allotted. M.J. remains alert and oriented, her neurovascular assessments remain within normal parameters, with pulses strong and equal, and capillary refill <3seconds. M.J. verbalizes feeling severely anxious regarding her pain and her concern for how long the neighbor can watch her children. The nurse prepares to call the on-call health care provider (HCP) to discuss M.J.'s situation. Name: M.J. Health Care Provider: J. S., MD Code Status: Full Code Age: 32 years Allergies: NKDA VITAL SIGN RECORD Time BP HR RR Sat Temp Pain Medication (MAP) Level (1-10) 2015 128/80 (96) 95 16 95 98.8 F (37.1 C) 8 Oxycodone/Acetaminophe n 2 tabs oral 2200 120/78 82 14 95 98.8 F (37.1 C) 5 Morphine 1 mg IV 2400 155/85 99 18 96 100.0 F (37.8 C) 8 Morphine 2 mg IV 0200 150/82 102 18 96 99.8 F (37.7 C) 6 Oxycodone/Acetaminophe n 2 tabs oral 0400 125/75 80 14 95 97.8 F (36.5 C) 8 Morphine 2 mg IV 0600 120/70 95 14 95 99.8 F (37.7 C) 5 Morphine 1 mg IV 0800 138/78 99 18 96 100.0 F (37.8 C) 6 Oxycodone/Acetaminophe n 2 tabs oral 8. Evaluate the information within the nurse's assessment and vital sign record and pick the Top 3 Priority assessment concerns. a.__________________________________________________________________________ b.__________________________________________________________________________ c.__________________________________________________________________________ 9. The nurse gathers information and begins to prepare an SBAR telephone conversation for the HCP. Complete each section of the SBAR communication. S-__________________________________________________________________________ B-__________________________________________________________________________ A-__________________________________________________________________________ R-__________________________________________________________________________ The HCP prescribes to discontinue the morphine sulfate and the oxycodone with acetaminophen and to begin hydromorphone via a Patient Controlled Analgesia (PCA). Also prescribed is a social services consultation to assist M.J.'s home situation of her children. The HCP and the nurse discuss preparing M.J. for surgery, which is scheduled for the afternoon. The HCP changes the pain medication prescription for M.J. stating "Let's get her pain better controlled." The prescription reads as follows: Name: M.J. Health Care Provider: J. S., MD Code Status: Full Code Age: 32 years Allergies: NKDA HEALTH CARE PROVIDER PRESCRIPTIONS Dec 3 0830 1. Discontinue morphine sulfate. 2. Discontinue oxycodone/acetaminophen. 3. PCA: hydromorphone 1 mg/mL. A. Loading dose 2 mg IV. B. Basal rate of 0.5 mg hourly. C. Demand dose of 1 mg. D. Lockout interval: 20 minutes. 4. Assessment of respiratory rate, sedation score, and pain control every 2 hours. 5. Alprazolam 0.25 mg orally twice daily as needed for anxiety. 6. Naloxone 0.4 mg IV as needed, may repeat every 20 minutes; notify HCP if administered. 7. Docusate sodium 100 mg orally twice daily. 8. Social services consultation. 10.Explain each of the prescriptions and its purpose, specific to M.J.'s care. In other words, why is it being prescribed? A. PCA: hydromorphone 1 mg/mL. __________________________________________________________________________ B. Loading dose 2 mg IV. __________________________________________________________________________ C. Basal rate 0.5 mg hourly. __________________________________________________________________________ D. Demand dose 1 mg. __________________________________________________________________________ E. Lockout interval: 20 minutes. __________________________________________________________________________ F. Assessment of respiratory rate, sedation score, and pain control every 2 hours. __________________________________________________________________________ G. Alprazolam 0.25 mg orally twice daily as needed for anxiety. __________________________________________________________________________ H. Naloxone 0.4 mg IV as needed, may repeat every 20 minutes; notify HCP is administered. ___________________________________________________________________________ I. Docusate sodium 100 mg orally. ___________________________________________________________________________ J. Social services consultation. ____________________________________________________________________________ 11. The nurse is reviewing the prescriptions and anticipates the possibility of administering the naloxone. Which description would indicate the proper rationale for the nurse to administer this medication? A. The client has a decrease in alertness; vital signs remain within desired parameters. B. The client has a decrease in the level of consciousness and breathing pattern as a result of alprazolam. C. The client has a decrease in the level of consciousness and breathing patterns as a result of the hydromorphone. D. The client's pain and anxiety goals are unmet, and there is the need for adjuvant therapy for better control. 12. The nurse is reviewing the side effects of naloxone. What clinical manifestations can the nurse expect to find after its administration? A. Rapid pulse, nervousness and constipation. B. Urticaria, drowsiness and nausea and vomiting. C. Increased BP and ventricular arrythmias. D. Respiratory depression, palpitations, and urinary retention. 13. Acute pain and chronic pain differ in cause, the course of progression, manifestations, and treatment. Fill in the blank areas in the table to differentiate between acute and chronic pain. Acute Pain Chronic Pain Onset Gradual or sudden Duration Greater than 3 months Severity Course of Pain Does not go away Anticipated physical and behavioral manifestations  Flat affect  Decreased physical activity  Fatigue  Withdrawal from social interaction Goal of treatment Pain control with eventual elimination The nurse receives the hydromorphone medication, PCA machine, and begins to gather equipment for the infusion. 14. The nurse considers the teaching components and importance in helping M.J. have adequate pain control. Before the teaching, what is most important for the nurse to assess? A. How much pain medication the client has received. B. The client's readiness and willingness to learn. C. When the client is going to be discharged. D. At what time the client will be going to surgery. 15. The nurse is preparing to teach M.J. about the PCA machine and important considerations. Which instructions are essential for the nurse to give the client? Select all that apply. A. Emphasize the safety features of the machine. B. Plan to teach the client in the perioperative period rather than postoperatively. C. How to self-administer the pain medication. D. Wait for the nurse's assistance when feeling the need for pain medication. E. As the pain lessens, the client can adjust to lower doses and eventually stop the analgesic. 16. The nurse is entering M.J.'s room with the PCA machine, supplies, and prescribed medication. What are the priority safety measures required before PCA narcotic administration? T-_________________________________________________________________________ H-_________________________________________________________________________ I-__________________________________________________________________________ N-_________________________________________________________________________ Name: M.J. Health Care Provider: J. S., MD Code Status: Full Code Age: 32 years Allergies: NKDA PCA PAIN MANAGEMENT FLOW SHEET Date: Dec. 3 Shift 0600-1800 Medication Hydromorphone Concentration 1 mg/mL PCA Dose____________ mg (See HCP prescriptions and supplies from pharmacy) CONTINUOUS DOSE_____________ mg/hour Time Location of Pain Pain Rating Level of Arousal # of demand doses # delivered Basal rate Cum Total (mg) Cum Total (mL) Notes 0930 Fingers Wrist 7 2 0 0 0 2 2 1030 Fingers Wrist 4 2 2 2 0.5 mg 1130 Fingers Wrist 5 1 2 2 1230 Fingers Wrist 5 2 2 0.5 mg 10 10 1330 Fingers Wrist 3 2 1 1 0.5 mg 11.5 11.5 Transferred to s..>@1430 1430 Fingers Wrist 2 2 1 0.5 mg Cumulative Shift Totals ASSESSMENT PARAMETERS Level of Arousal 1 Awake & Alert 2 Normal Sleep 3 Difficult to 4 Responds to 5 Does not Oriented Easy to Rouse to Verbal Stimulation Rouse to Verbal Stimulation Physical Stimulation Respond to Verbal or Physical Stimulation 18.Based on a review of the PCA flow sheet what can the nurse determine about M.J.’s use of the PCA machine and medication? Select all that apply. A. The amount of medication she is demanding supersedes the amount delivered. B. The level of arousal indicates she is receiving too much medication. C. The machine delivers a specific amount of medication each hour regardless of her demands. D. The demand for medication was greatest when her pain level was the highest. E. The least amount of medication was delivered when her pain was at “2.” Molly was transferred to the operating room at 1430 for surgical wound debridement of her fingers and forearm, and placement of an anterior forearm skin graft. The PCA medication is placed into a locked system while she is off the unit. Several hours later she returns to the burn unit. Name: M.J. Health Care Provider: J. S., MD Code Status: Full Code Age: 32 years Allergies: NKDA NURSING NOTES Dec 3 1800 Returns to room with eyes closed, drowsy, oriented x 3, BP 115/67 (83), HR 75, respirations 12, temp 98.3 F (36.8 C). Pain rating 2 on a 1-10 scale. States feeling nauseated. Left fingertips are warm, pink, and with good movement. Gauze dressing in place near the middle of the fingers, covering left hand and forearm. Positioned for comfort, warm blankets provided bed in low position and locked. Call light within reach. Continue to monitor. Name: M.J. Health Care Provider: J. S., MD Code Status: Full Code Age: 32 years Allergies: NKDA HEALTH CARE PROVIDER POST-OPERATIVE PRESCRIPTIONS Dec 3 1800 1. Bedrest; assist to the bathroom; ambulate in the morning. 2. Ice chips, advance to regular diet; encourage protein. 3. PCA: hydromorphone 1 mg/mL. A. Loading dose 2 mg IV. B. Basal rate of 0.5 mg hourly. C. Demand dose of 1 mg. D. Lockout interval: 20 minutes. 4. Page the healthcare provider for any problems with the patient’s level of pain control, the presence of side effects, if 1-hour limit is reached before 1 hour with poor pain relief and/or if sedation score =3. 5. Assessment of respiratory rate, sedation score, and pain control every 2 hours. 6. Alprazolam 0.25 mg orally twice daily as needed for anxiety. 7. Naloxone 2 mg IV as needed, may repeat every 20 minutes; notify HCP if administered. 8. Ringers Lactate 75 mL/hour. 9. Famotidine 20 mg orally twice daily. 10. Docusate sodium 100 mg orally twice daily. 11. Ascorbic acid 500 mg orally three times daily. 12. Surgical team to be present for the first dressing change in 24 hours. M.J. and the nurse discuss her desires for adequate pain control and identify what an acceptable pain level is. M.J. verbalizes a 2 to 3 on the 1 through 10 numerical rating scale as tolerable. M.J. has been informed that her parents are arriving from out of town and will care for the children until her discharge. I ONLY NEED HELP FOR NUMBER 19 THIS ARE THE INFORMATION Image transcription text 19. Complete the PCA flow sheet by filling in the shaded areas: Nursing Flow Sheets Frovider Labs & Diagnostics MAR Collaborative Care Other Nurse Name: Molly Juniper Age: 32 years . Think Health Care P… Show more SCIENCE HEALTH SCIENCE NURSING MEDSERG NUR 255

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