Exam (elaborations) NUR 3330 Charlie Raymond Room 302 Med-Surg (ALL EV

Exam (elaborations) NUR 3330 Charlie Raymond Room 302 Med-Surg (ALL EV harlie Raymond, 65-year-old male who was admitted to a negative pressure room on Med-Surg for COVID precautions.. He has a history of COPD, hypertension, diabetes type II, and a recent myocardial infarction. He is a retired postal worker who lives at home with his wife. He is on Claforan (cefotaxime) 2 g IV q4hr and sliding scale insulin. Initially this cardiologist was concerned about congestive heart failure and Mr. Raymond is receiving Furosemide (Lasix) 20 mg IV twice a day for pulmonary edema. Vital Signs: BP is 145/78, Pulse 89 Respirations 24 and slightly labored, Temperature 100.2 SaO2 94% on 2L nasal cannula. The patient/family is fearing the worst due to COVID-19 Pandemic. You responded correctly to 5 out of 6 evaluations: Category Your response Explanation Educational Needs Increased acuity Due to COVID-19. Fall Risk Increased acuity He has an IV and has O2 on. Health change Increased acuity Significant change in pulmonary status. Neurological Normal acuity Patient is AAO x4. Pain level Normal acuity Normal, rationale: Patient states the pain has subsided This study source was downloaded by from CourseH on :59:06 GMT -05:00 This study resource was shared via CourseH NUR 3330 Charlie Raymond Room 302 Med-Surg (ALL EVALUATIONS) Category Your response Explanation Psychological Needs Normal acuity Patient and family are fearing the worse as a result of COVID-19. Charlie Raymond 65-year-old male who was admitted to a negative pressure room on Med-Surg for COVID precautions.. He has a history of COPD, hypertension, diabetes type II, and a recent myocardial infarction. He is a retired postal worker who lives at home with his wife. He is on Claforan (cefotaxime) 2 g IV q4hr and sliding scale insulin. Initially this cardiologist was concerned about congestive heart failure and Mr. Raymond is receiving Furosemide (Lasix) 20 mg IV twice a day for pulmonary edema. Vital Signs: BP is 145/78, Pulse 89 Respirations 24 and slightly labored, Temperature 100.2 SaO2 94% on 2L nasal cannula. The patient/family is fearing the worst due to COVID-19 Pandemic. You correctly diagnosed 11 out of 11 options: This study source was downloaded by from CourseH on :59:06 GMT -05:00 This study resource was shared via CourseH Physiological Description Your Response Explanation Bleeding False No evidence of hemorrhage. Death anxiety True Fear of death as a result of media/ high risk patient . Disturbed Body Image False No evidence of disturbed body image. Esteem False No evidence of decreased esteem. Impaired Acute Confusion False No indication at this time. Impaired Gas Exchange True Evidence of Pulmonary edema. Ineffective breathing pattern True Respiratory rate of 24 and labored. Knowledge deficit False Patient/Family need education on isolation procedures. Pain, Acute False No evidence of pain. Physical Mobility, Impaired False No evidence of impairment. Skin Integrity False No indication at this time. You correctly ordered 5 out of 5 actions: Your order Correct order Step Explanation 1 1 Don appropriate PPE. Per CDC guidelines. 2 2 Change to simple O2 face mask per Healthcare provider. Simple face mask provides greater concentration of O2. 3 3 Perform focused respiratory assessment. The patient is in respiratory distress. 4 4 Notify respiratory therapist to begin treatment. Aggressive pulmonary treatment is required. 5 5 Notify family to self-isolate for 14 days. Per CDC guidelines to prevent spread of infection. Scenario 2 This study source was downloaded by from CourseH on :59:06 GMT -05:00 This study resource was shared via CourseH You correctly ordered 3 out of 5 actions: Your order Correct order Step Explanation 1 1 Reorient patient to setting using therapeutic communication. To reduce confusion, and facilitate safety. 5 2 Obtain a sitter/UAP. To promote safety and assist nurse with procedures. 3 3 Restart the IV. Necessary for IV antibiotic treatment. 4 4 Begin strict I&O. Patient has a history of cardio-pulmonary disease because due to risk for acute changes of fluid volume status. Implement I&O before obtaining order to insert foley. 2 5 Obtain an order to insert a foley catheter. To monitor strict I&O, because patient is receiving Lasix and confusion. Scenario 3 You correctly ordered 5 out of 5 actions: Your order Correct order Step Explanation 1 1 Use therapeutic communication to explain necessary procedure. In order to reduce confusion and maximize cooporation. 2 2 Position the patient properly. To minimize risk of movement before insertion to help maintain sterile field. 3 3 Create sterile field with foley kit on the bedside table and don sterile gloves. Reduces the risk of infection due to proximity of patient to the sterile field. 4 4 Instruct Lucy to assist in maintaining patient position and field Best practices require a second licensed witness This study source was downloaded by from CourseH on :59:06 GMT -05:00 This study resource was shared via CourseH Your order Correct order Step Explanation sterility. during an insertion of a foley catheter. 5 5 Insert foley catheter according to hospital recommended guidelines,to ensure sterility of catheter. Reduce the risk of catheter associated urinary tract infection (CAUTI). Scenario 4 You correctly ordered 5 out of 5 actions: Your order Correct order Step Explanation 1 1 Make sure O2 mask is secure and free of sputum. Maintain proper function of mask, sputum could cause mask to be less effective. 2 2 Ensure patient is in fowlers position. Respiratory status is less compromised in a fowler’s position. 3 3 Check the foley catheter to make sure it is not obstructed. Ensure accurate output. 4 4 Notify Rapid Response team (RRT). Deteriorating condition necessitates immediate intervention by RRT. 5 5 Provide initial report and assist RRT. RRT needs immediate information on history/condition of patient. You correctly ordered 5 out of 5 actions: Your order Correct order Step Explanation 1 1 Mr. Raymond, COVID-19 positive, in severe respiratory distress, rapid response called. According to SBAR: Situation. This study source was downloaded by from CourseH on :59:06 GMT -05:00 This stu