STUDENT-COVID-19-Part-II-Med-Surg-UNFOLDING_Reasoning

1. After receiving SBAR report, in one sentence describe the ESSENCE of the patient problem that will guide your plan of care. (NCLEX: Management of Care) Patient is covid 19 positive and slightly declining in status vital signs wise, need to continue o2 and monitor status closely. Admitted to Med/Surg: Fifteen Minutes Later… Current VS: Most Recent in ED: Current PQRST: T: 101.2 F/38.8 C (oral) T: 100.6 F/38.8 C (oral) Provoking/Palliative: “moving makes it worse” P: 120 (regular) P: 112 (regular) Quality: “achy” R: 24 (regular) R: 20 (regular) Region/Radiation: “all over” BP: 122/68 MAP: 86 BP: 152/84 MAP: 107 Severity: 5/10 O2 sat: 94% 2 liters n/c O2 sat: 93% 2 liters n/c Timing: continuous 2. What VS data are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: TREND: Improve/Worsening/Stable: T: 101.2 Fever, body is fighting Worsening P:120 Body is trying to compensate for lack of oxygen worsening R:24 Body is trying to compensate for lack of oxygen worsening BP:122/68 Abnormally low for hx of htn worsening Current Head to Toe Nursing Assessment: GENERAL SURVEY: Appears anxious, body tense and is sitting upright in bed NEUROLOGICAL: Alert & oriented to person, place, time, and situation (x4), nods head and uses gestures to avoid talking. Generalized weakness. HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and moist. RESPIRATORY: Breath sounds light crackles bilat. with diminished aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, slightly labored respiratory effort, persistent non-productive cough. CARDIAC: No edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. ABDOMEN: Abdomen round, soft, and nontender. BS active in all 4 quadrants, has no appetite. GU: Reports last void was appx. three hours ago. No pain or burning with urination. INTEGUMENTARY: Skin hot, dry, intact, normal color for ethnicity. Skin integrity intact, skin turgor elastic, no tenting present. 3. What assessment data is RELEVANT and must be NOTICED as clinically significant by the nurse? ..........................................CONTINUED.........................................