QuestionUNFOLDING Clinical Reasoning Case Study: Infection & Oxygenation Simulation I. Data Coll

QuestionUNFOLDING Clinical Reasoning Case Study: Infection & Oxygenation Simulation I. Data CollectionHistory of Present Problem:     Susan Smith is a 33-year-old woman who developed urinary frequency and lower back pain that worsened over several days. She took several medications at home, but the pain did not go away. After eight days, she developed moderate breathlessness and presented to the Emergency Room with the following physical exam: Neuro: A&Ox3, moves all extremities, PERRL 3mm, reports 8/10 lower back and flank pain.Vital signs: T 101.4 temporal artery, HR 105, RR 29, BP 108/72mmHg, O2 Saturation 92% on room airCardiovascular: Heart sounds S1/S2, no murmur appreciated, no JVD noted, + pedal pulses bilaterally, trace pedal edema bilaterally, cool, pale extremities, capillary refill < 3 secondsRespiratory: Fine crackles auscultated bilateral lower lobes posteriorly, use of intercostal accessory muscles noted, equal expansion of lungs notedGastrointestinal: + bowel sounds x4 quadrants, non-tender, softGenitourinary: Foley catheter placed with cloudy amber colored urine, + sediment, + foul odorSkin: cool, pale, intact Personal/Social History: Lives with husband and one young child in a private home. Smokes ½ pack per day (ppd). Reports drinking alcohol socially, approximately 2 times per month.  Past Medical History:Urinary tract infectionAnxietyGravida 1, para 1Home Medication List:Acetaminophen 650mg PO Q6H PRNIbuprofen 600mg PO Q8H PRNLorazepam 0.5mg PO TID PRN What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse? (2b)RELEVANT Data from Present Problem: Clinical Significance:       RELEVANT Data from Social History: Clinical Significance:              What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (2c)(Which medication treats which condition? Draw lines to connect.)PMH: Home Meds: Pharm. Classification: Expected Outcome:    1.2.3. 1.2.3.  One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology, (if applicable), which disease likely developed FIRST that then initiated a “domino effect” in their life? (2c)Circle what PMH problem likely started FIRST.Underline what PMH problem(s) FOLLOWED as domino(s). II. Patient Care Begins: Current VS:    WILDA Pain Assessment (5th VS):T:   102.3 (oral) Words: Constant, burning, aching, sharpP: 128bpm (regular) Intensity: 9/10 on a scale of 0-10R:   27 (regular) Location: Left flankBP: 102/71 mmHg Duration: Multiple daysO2 sat: 94% on 2L nasal cannula Aggravate:Alleviate: MovementNothingWhat VS data is RELEVANT that must be recognized as clinically significant to the nurse? (2b)RELEVANT  VS Data: Clinical Significance:           Current Assessment:GENERAL APPEARANCE: Appears anxious, sitting upright in bed leaning forwardRESP: Breath sounds crackles bilaterally posteriorly, intercostal retractions, pursed lip breathingArterial blood gas result: pH 7.49, PaCO2 28, PaO2 64, HCO3 24CARDIAC: Pallor, cool & dry, non-pitting 1+ pedal edema, heart sounds regular with no abnormal beats, pulses weak, equal with palpation at radial/pedal/post-tibial landmarksNEURO: Alert & oriented to person, place, time, and situation (x4)GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrantsGU: Foley catheter remains in place from the emergency room. Urine cloudy amber with sediment, foul odor.SKIN: Skin integrity intact   What assessment data is RELEVANT that must be recognized as clinically significant to the nurse?(2a, 2b, 2c)RELEVANT  Assessment Data: Clinical Significance:             Cardiac Telemetry Strip:  Interpretation (2b):   Clinical Significance (2c):  Evidence-based practice interventions (2b, 3a, 3b, 5a)  III. Clinical Reasoning Begins…1. What is the primary problem that your patient is most likely presenting with? (2c)   2. What is the underlying cause/pathophysiology of this concern? (2c)   3. What nursing priority(s) captures the “essence” of your patient’s current status and will guide your plan of care?(if more than one-list in order of PRIORITY) (2b, 3a, 3b)      4. What interventions will you initiate based on this priority? (2b, 3a, 3b)Nursing Interventions: Rationale: Expected Outcome:               5. What body system(s) will you most thoroughly assess based on the primary problem or nursing care priority? (2b)  6.   What is the worst possible/most likely complication to anticipate based on the primary problem? (2c, 5a)  7.   What nursing assessments will identify this complication EARLY if it develops? (2b, 3a, 3b)  8.   What nursing interventions will you initiate if this complication develops? (2b, 3a, 3b, 5a)     Medical Management: Rationale for Treatment & Expected OutcomesCare Provider Orders: Rationale: Expected Outcome:Activity:  Bedrest; maintain HOB 30-45 degreesDiet:  NPOVital Signs: Every 4 hoursMonitor strict I&OsApply sequential compression devices to bilateral lower extremitiesMaintain O2 saturation >95% on 2-4L nasal cannulaChest X-RayComplete Blood CountBasic Metabolic Panel     PRIORITY Setting: Which Orders Do You Implement First and Why? (2b)Care Provider Orders: Order of Priority: Rationale:     1.2.3.4.5.6.   Radiology Reports:What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse? (2b, 2c)RELEVANT Results: Clinical Significance:Chest X-ray demonstrated bilateral infiltrates     Lab Results (2b, 2c): What lab results are RELEVANT that must be recognized as clinically significant to the nurse?Complete Blood Count (CBC:) Current: High/Low/WNL? Previous:WBC  19.5   12.8Hgb  15.4   15.1Hct  46   45Platelets 424   401Neutrophil %  75%   72%Band forms 5%   3%         What lab results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Lab(s):  Clinical Significance: TREND:  Improve/Worsening/Stable:                                 Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Previous:Sodium (135-145 mEq/L) 138   135Potassium (3.5-5.0 mEq/L) 3.8   4.0Chloride (95-105 mEq/L) 100   102CO2 (Bicarb) (21-31 mmol/L) 19   21Anion Gap (AG) (7-16 mEq/l) 10   12Glucose (70-110 mg/dL) 78   88Calcium (8.4-10.2 mg/dL) 9.5   9.2BUN (7-25 mg/dl) 22   16Creatinine (0.6-1.2 mg/dL) 1.0   0.9            RELEVANT Lab(s):  Clinical Significance: TREND:  Improve/Worsening/Stable:                                Misc. Labs: Current: High/Low/WNL? Previous:Lactate 4.3   2.1    RELEVANT Lab(s):  Clinical Significance: TREND:  Improve/Worsening/Stable:                                 Urine Analysis (UA:) Current: WNL/Abnormal?Color  Amber  Clarity  Cloudy  Specific Gravity  1.020  Blood  positive  LET (Leukocyte Esterase) + heavy   MICRO:    RBC’s (<5) 8  WBC’s (<5) 201  Bacteria (neg) + positive              RELEVANT Lab(s):  Clinical Significance:      Cardiac Labs: Current: High/Low/WNL?BNP (B-natriuretic Peptide)  98      RELEVANT Lab(s):  Clinical Significance:      Microbiology Test Organism Clinical SignificanceUrine Culture Escherichia Coli (E. Coli) >100,000 colonies/mL     Blood Culture # 1 Escherichia Coli (E. Coli) >50,000 colonies/mL    Blood Culture # 2 PendingPreliminary report: gram negative rods, moderate growth      Lab Planning: Creating a Plan of Care with a PRIORITY Lab (2b, 3a, 3b): Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required:                IV. Clinical Reasoning-Lab Results:Does your initial nursing priority or plan of care need to be modified in any way after obtaining these lab results?(3a)  What are your current nursing priorities that will determine your plan of care? (2b)   You are preparing to call the provider with an update on the client’s status and diagnostic test results. Complete this SBAR form with what you would include in your update (1a, 1b, 2e): Situation:    Background:    Assessment:     Recommendation:   V. Evaluation: Evaluate the response of your patient to nursing & medical interventions during your shift. All physician orders have been implemented that are listed under medical management. Twenty four hours later:   S. Smith was transferred to the Intensive Care Unit overnight due to clinical manifestations of septic shock. She was started on vancomycin and piperacillin-tazobactam for her positive blood and urine cultures. 0.9% NaCl @ 200 mL/hr was initiated per the hospital sepsis protocol.   Her breathing deteriorated and she required mechanical ventilation for respiratory failure. Ventilating S. Smith became more difficult, which required an increase in her positive end-expiratory pressure (PEEP) on the mechanical ventilator and administration of a neuromuscular blockade; vecuronium, and sedation; propofol. The increase in PEEP resulted in barotrauma and a spontaneous left pneumothorax. A chest tube with a dry-suction drainage system was placed by the thoracic surgeon without complication. Medication Relevance (3b, 5a)Medication:  Pharm. Class: Mechanism of Action: Nursing Assessment/Considerations:Vancomycin Piperacillin-tazobactam  Vecuronium Propofol       Medication Math:(please refer to pg. 634-637 of your Calculate with Confidence book for guidance)Order: Continuous Propofol infusion for sedation, titrate per sedation score Start at 5mcg/kg/min  Titrate infusion by 5mcg/kg/min Goal sedation score is -1Maximum dose is 70mcg/kg/min   Available: Propofol 1000mg in 100mLDetermine the flow rate in mL/hr for the following titration table:Dose: 5mcg/kg/minMinimum rate Flow rate: Dose: 25mcg/kg/min Flow rate:Dose: 40mcg/kg/min Flow rate:Dose: 70mcg/kg/minMaximum rate Flow rate:  Current VS:    Most Recent: Current WILDA:  T:  101.2 (axillary)   Words: Non-verbal due to endotracheal tube in place. Wong-Baker Face scale used instead.P:   97 bpm (reg)   Intensity: 3 via wong-baker face scaleR:  20 per minute via mechanical ventilation   Location: undeterminedBP:  100/70mmHg   Duration: undeterminedO2 sat: 96% on 75% FiO2 via mechanical ventilation   Aggravate:Alleviate: Turn and repositioningAnalgesic medication Current Physical Assessment:GENERAL APPEARANCE: Resting comfortably in bed on current sedation settings. Endotracheal tube in place. Bilateral soft-wrist restraints in place.RESP: Mechanically ventilated on the ventilator. Breath sounds are fine crackles bilateral bases.Arterial blood gas result: pH 7.40, PaCO2 38, PaO2 82, HCO3 25CARDIAC: Pink, cool & dry, trace non-pitting pedal edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarksNEURO: Sedated on current sedation settings, opens eyes to physical stimulus, unable to follow commands.GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrantsGU: Foley catheter remains in place, urine yellow and cloudy, no odor.SKIN: Skin intactNursing Assessment (2b): What clinical data is RELEVANT that must be recognized as clinically significant? (2b, 3a, 3b) RELEVANT VS Data: Clinical Significance:           RELEVANT Assessment Data: Clinical Significance:           Has the status improved or not as expected to this point? (2c)Based on your current evaluation, what are your nursing priorities and plan of care? (2b, 3a)  3.   Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? (3a)      VI. Education Priorities/Discharge PlanningMrs. Smith recovered over the course of 5-days. The endotracheal tube was removed, and she is waiting for an available bed on the medical-surgical floor. The provider has written orders to maintain the chest tube in place. The left-sided chest tube is intact and is connected to low wall suction at -20cm H2O per provider order. Mrs. Smith is voicing concerns that this could happen to hear again someday. She states that she was afraid she was going to die. 1.   What will be the most important discharge/education priorities you will reinforce with their medical condition to prevent future readmission with the same problem? (1a, 2b, 3a, 4a)     What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?(1a, 4a)    VII. Caring and the “Art” of Nursing (1a, 2d, 5a)What is the patient likely experiencing/feeling right now in this situation?    What can you do to engage yourself with this patient’s experience, and show that he/she matter to you as a person?         Health ScienceScienceNursingNUR 1025Share Question

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