PRIORITY Patient Activity Part
II: Initial Assessment/Interprofessional Communication
Herbie Saunders, 62 years old David Mueller, 71 years old Gladys Parker, 92 years old
CHF Exacerbation Below-the-Knee Amputation Weakness and Falls
NCLEX Client Need Categories Percentage of Items from Covered in
Each Category/Subcategory Case Study
Safe and Effective Care Environment
✓ Management of Care 17-23% ✓
✓ Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12% ✓
Psychosocial Integrity 6-12%
Physiological Integrity
✓ Basic Care and Comfort 6-12%
✓ Pharmacological and Parenteral Therapies 12-18%
✓ Reduction of Risk Potential 9-15% ✓
✓ Physiological Adaptation 11-17% ✓
© 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or
transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior
This study source was downloaded by 100000830772748 from CourseHero.com on 02-12-2022 03:05:50 GMT -06:00
https://www.coursehero.com/file/105806424/STUDENT-PART-II-Priority-Ptpdf/
, written permission of KeithRN
It is now 7:45 am. You have received reports for each of your three patients
on the med-surg unit of Anytown General Hospital, reviewed their charts,
and are ready to begin your day.
You have elected to assess them in the following order based on the
information you were given from the overnight nurses:
1) Herbie Saunders
2) Gladys Parker
3) David Mueller
Initial Assessment
Initial Assessment
Patient #1: Herbie Saunders
Vital Signs @ 0715 What Do You Notice? Clinical Significance:
T: 98.4° F (oral) Patient’s HR is elevated, up The patient’s heart is having to
P: 110 from 76 to 110. Slight increase pump/work harder to be able to
in RR and systolic BP distribute the oxygenated blood
R: 24
to the body
BP: 132/78 (MAP 96 mmHg)
O2 sat: 91% on room air
Pain: denies
Daily Weight: 198.4 lb (90.2 kg)
Fingerstick: 147
Focused Patient Assessment: What Do You Notice? Clinical Significance:
As you enter the room, Mr. Saunders is sitting in The patient has dyspnea, RR has The patient’s movement may
the recliner breathing heavily. He states, with increased and low O2 saturation have caused an exacerbation,
some difficulty, “I can’t….believe…..how and visible worsening of
winded….I am right now. I just….had….to condition CHF should
go….to the bathroom.” Respirations are 28 and
immediately given to MD after
his continuous oxygen monitor reads 87%. He is
providing O2 and returning to
on room air.
bed.
Before you continue with your assessment, what nursing interventions need to be implemented right away?
Patient will be placed on the bed, with the head of the bed elevated and O2 via nasal cannula will be
administered to help increase the patient’s breathing and O2 saturation.
This study source was downloaded by 100000830772748 from CourseHero.com on 02-12-2022 03:05:50 GMT -06:00
https://www.coursehero.com/file/105806424/STUDENT-PART-II-Priority-Ptpdf/
II: Initial Assessment/Interprofessional Communication
Herbie Saunders, 62 years old David Mueller, 71 years old Gladys Parker, 92 years old
CHF Exacerbation Below-the-Knee Amputation Weakness and Falls
NCLEX Client Need Categories Percentage of Items from Covered in
Each Category/Subcategory Case Study
Safe and Effective Care Environment
✓ Management of Care 17-23% ✓
✓ Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12% ✓
Psychosocial Integrity 6-12%
Physiological Integrity
✓ Basic Care and Comfort 6-12%
✓ Pharmacological and Parenteral Therapies 12-18%
✓ Reduction of Risk Potential 9-15% ✓
✓ Physiological Adaptation 11-17% ✓
© 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or
transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior
This study source was downloaded by 100000830772748 from CourseHero.com on 02-12-2022 03:05:50 GMT -06:00
https://www.coursehero.com/file/105806424/STUDENT-PART-II-Priority-Ptpdf/
, written permission of KeithRN
It is now 7:45 am. You have received reports for each of your three patients
on the med-surg unit of Anytown General Hospital, reviewed their charts,
and are ready to begin your day.
You have elected to assess them in the following order based on the
information you were given from the overnight nurses:
1) Herbie Saunders
2) Gladys Parker
3) David Mueller
Initial Assessment
Initial Assessment
Patient #1: Herbie Saunders
Vital Signs @ 0715 What Do You Notice? Clinical Significance:
T: 98.4° F (oral) Patient’s HR is elevated, up The patient’s heart is having to
P: 110 from 76 to 110. Slight increase pump/work harder to be able to
in RR and systolic BP distribute the oxygenated blood
R: 24
to the body
BP: 132/78 (MAP 96 mmHg)
O2 sat: 91% on room air
Pain: denies
Daily Weight: 198.4 lb (90.2 kg)
Fingerstick: 147
Focused Patient Assessment: What Do You Notice? Clinical Significance:
As you enter the room, Mr. Saunders is sitting in The patient has dyspnea, RR has The patient’s movement may
the recliner breathing heavily. He states, with increased and low O2 saturation have caused an exacerbation,
some difficulty, “I can’t….believe…..how and visible worsening of
winded….I am right now. I just….had….to condition CHF should
go….to the bathroom.” Respirations are 28 and
immediately given to MD after
his continuous oxygen monitor reads 87%. He is
providing O2 and returning to
on room air.
bed.
Before you continue with your assessment, what nursing interventions need to be implemented right away?
Patient will be placed on the bed, with the head of the bed elevated and O2 via nasal cannula will be
administered to help increase the patient’s breathing and O2 saturation.
This study source was downloaded by 100000830772748 from CourseHero.com on 02-12-2022 03:05:50 GMT -06:00
https://www.coursehero.com/file/105806424/STUDENT-PART-II-Priority-Ptpdf/
