Cardiac specific. CK-MB CRP Chest X-ray (as time allows – shows cardiac and aortic arch silhouette, pulmonary edema) Echocardiogram (as time allows – will show movement abnormalities and ejection fraction) From a brief history, the nurse learns that Mr Walters is a 52 year old engineer who began experiencing chest discomfort about an hour ago. He would not allow his wife to call 911, but allowed her to drive him to the hospital. He has not taken any medication for his chest discomfort. He has a history of hypertension, hyperlipidemia, and non-insulin dependent diabetes but is
foundations Foundations in Nursing HLTEN504B Implement and evaluate a plan of nursing care. Sharon Laing 2300612001 Feb/March 2013 – Part Time Assessment Task 1. Q1 Cerebrovascular Accident (CVA) Caused by clot, haemorrhage or emboli affecting a blood vessel leading to or within the brain.Creates altered sensory stimuli with marked loss of balance and coordination in the side affected. (Crisp, Taylor, Douglas & Rebeiro, 2009 p.1390) Dysphagia –Difficulty in swallowing. (Crisp, Taylor, Douglas & Rebeiro, 2009 p.1131) Socially Withdrawn – due to grief from her husband’s death and the Hindu religion has a 12 month mourning period.
NURSING DIAGNOSIS:Impaired physical mobility1 | RELATED TO: Loss of integrity of bone structures (S/P right knee surgery)Pain (reported 7/10. Acceptable =3)2 | AEB:Limited ability to perform gross motor skills (Pt unable to ambulate without assistance)Difficulty turning (Pt unable to turn side to side unassisted)3 | PLANNING (Expected Outcome):By end of shift, pt will be able to ambulate 100’ with P.T. twice (BID)By end of shift, pt will be able to turn in bed unassisted.4 | INTERVENTIONS5NI # 1Medicate with Vicodin 1-2 pills q4h throughout shift whenever pt reports pain level greater than 3. | Rationale:6Vicodin is an opioid analgesic that is effective in post-surgical patients by binding to opioid receptors to block pain transmission
Cystic Fibrosis Meet the Client: Debbie Baker Paula and David Baker bring their 3-year-old adopted Caucasian daughter, Debbie, to the pediatrician reporting that she has recently been having large, greasy-looking stools. The pediatrician notes that Debbie has fallen below the 10th percentile in height and weight. Debbie appears to be unhealthy and is very listless. Clinical Manifestations The pediatrician suspects that Debbie may have cystic fibrosis (CF). 1.
By 1350 she was complaining of back pain of 9/10 and she was given Morphine 2mg IVP and denied any pain 10 minutes later. Come 1530 the patient’s vitals were stable on room air, she ambulated to the bathroom independently and at 1535 a loud thud was heard in the bathroom. The patient was found lying on the floor with a laceration above her left eyebrow, not responsive to verbal commands and breathing at a rate of 4 per minute. We will discuss the immediate concerns and treatment for the patient and then we will go back and see what could have been done differently with the patient to prevent the situation that occurred. The nurse immediately assessed the ABC’s and activated the MET team.
Which response is best for the nurse to provide? -The clip feels like squeezing your finger with your other hand The nurse meausres Josh’s oxygen saturation at 88% and capillary refill at 1 second. Breath sounds are absent at the base and coarse bilaterally throughout the rest of the lung fields. The nurse administers a 2 liter nasal cannula. When applying the nasal cannula it is important for the nurse to provide which instructions -Remind the client and family that oxygen is combustible and stay 10 ft away from open flames Which nursing diagnosis is most relevant to josh’s current status?
Cystic Fibrosis Meet the Client: Debbie Baker Paula and David Baker bring their 3-year-old adopted Caucasian daughter, Debbie, to the pediatrician reporting that she has recently been having large, greasy-looking stools. The pediatrician notes that Debbie has fallen below the 10th percentile in height and weight. Debbie appears to be unhealthy and is very listless. Clinical Manifestations The pediatrician suspects that Debbie may have cystic fibrosis (CF). 1.
Question 1 - INCORRECT | Your patient is admitted with a diagnosis of a intracerebral hemorrhage due to an aneurysm. On admission your patient’s pupils were equal and reactive to light, she had a slight drift of the right arm and complaints of a headache and nausea. About 15 minutes later she is unresponsive and her pupils are dilated and react sluggishly. You would anticipate her treatment is likely to include: | | | Your Answer: | Administration of t-PA | | Rationale: Incorrect. Please review Module 5, Lesson 4, Topic 4 | | A surgical aneurysm clipping | | Rationale:Correct | | | Question 2 - Correct | The clinical presentation of a patient with a brain tumor depends on the location of the tumor.
Identifying information: 76 y/o Caucasian male Source and reliability: Friend to a family member, seems reliable Chief Compliant: Left leg pain and swelling x 3days History of present illness: He first felt some pain on the left leg from the groin down to the feet three days ago, onset sudden. Reports pain felt intense and sharp-like, localized to the left leg; rated as a 9 on a numeric scale of 1-10. Pain is worse with movement, standing and bending of knee especially calf. Reports no relief with OTC Tylenol ES. Denies any change in exercises, prolonged standing/sitting, or bed rest.
Family Health History Patient states that grandparents on each side of her family passed away because of cancer. (see genogram on next page) Review of Systems General Symptoms – Patient complains of swollen/painful tongue and a rash on the inside of her thighs. Says pain in tongue is a 7 out of 10 when talking or eating. Integumentary – Patient describes skin as dry. Uses lotion and baby oil.