NR305 All Discussions Latest 2017 November

The topic this week asks you to apply what you have learned to the following case study.

Your home health agency has received an order from a local hospital to evaluate and treat an elderly woman being discharged from its medical surgical unit.

Millie Gardner, an 83-year-old female patient, is being discharged home today to the care of her husband Fred (87 years old) following a 9-day hospitalization for pneumonia, dehydration, and failure to thrive. She has a history of hypertension (HTN), Type II Diabetes, and cerebral vascular accident (CVA) with left-sided weakness. Patient is alert and oriented but does have periods of forgetfulness during the overnight hours. Patient has intermittent incontinence of bowel and bladder and requires assistance with all activities of daily living (ADLs).

Medications:

• Lopressor
• Lisinopril
• Plavix
• Metformin
• Novolin R per sliding scale *NEW*
• Multivitamin
• Colace
• Zithromax *NEW*

Upon arrival you are greeted by Champ, the couple's rambunctious miniature Doberman pinscher dog. Millie is in her wheelchair staring blankly out the window, and Fred is busy in the kitchen preparing the couple's lunch.

• Based on the scenario above, please use the general survey process to describe the areas that you would be observing immediately upon entry to the home.
• What, if any, concerns related to Millie's skin and nutritional status do you have?
• What nursing interventions will you include in the plan of care to address these concerns?
• What teaching strategies will you use to educate Millie and Fred on the new medications?
• Using the SBAR, please include the information that you will communicate to the physician's office at the completion of the visit.

Randy Adams is a 38-year-old male patient of Dr. Joseph Reynolds who was admitted yesterday morning for 24-hour observation for mild concussion following a motor vehicle accident. Randy lost consciousness during the accident and was very confused when he arrived in the ER after EMS transport. He is an Iraq war veteran and he seemed to think after the accident that this all happened in Iraq. Dr. Reynolds is concerned that Randy has some residual problems from a couple of explosive incidents that occurred while he was in Iraq. The physician is unsure whether Randy's current symptoms are from the car accident or from prior injuries so he has referred him for consultations to both a neurologist and to a behavioral health specialist.

Based on the above please discuss the following.

1. Pathophysiology of concussive injuries and treatment
2. Neurological assessment tools used in your current practice setting (if not presently working, please describe one used during prior employment or schooling)
3. Current best practices associated with post-traumatic stress disorder (PTSD)
4. Nursing interventions you would include in this patient's plan of care

Esther Jackson is a 56-year-old black female who is 1-day post-op following a left radical mastectomy. During morning rounds, the off-going nurse shares with you during bedside report that the patient has been experiencing increased discomfort in her back throughout the night and has required frequent help with repositioning. She states that the patient was medicated for pain approximately 2 hours ago but is voicing little relief and states that you might want to mention that to the doctor when he rounds later this morning. With the patient appearing to be in no visible distress, you proceed on to the next patient's room for report.

Approximately 1 hour later, you return to Ms. Jackson's room with her morning pills and find her slumped over the bedside stand in tears. The patient states, "I don't know what is wrong, I don't feel right. My back hurts and I'm just so tired. What is wrong with me?" The patient refuses to take her medications at this time stating that she is starting to feel sick to her stomach.

Just then the nursing assistant comes into the patient's room to record Ms. Jackson's vital signs, you take this opportunity to quickly research the patient's medication record to determine if she has a medication ordered for nausea. Upon return, the nursing assistant hands you the following vital signs: T 37, R 18, and BP 132/54, but states she couldn't get the patient's pulse because "it is all over the place."

Please address the following questions related to the scenario.

1. What do you suspect is the cause of the patient's symptoms?
2. Describe the course of action that you will take to confirm this suspicion and prevent further decline.
3. What further assessments, lab values, and tests will likely be ordered for this patient and how often? If testing is to be completed more than once, please explain the rationale for doing so.
4. While you are caring for this patient, how will you ensure that the needs of your other patients are being met?

Please review the video above as it will provide you with an opportunity to immerse yourself in the role of a nurse addressing tobacco use during routine patient care. In doing so, reflect on what you have learned about tobacco use and the role that nurses and other interdisciplinary team members play in helping to assist tobacco users with quitting. While viewing, it is also important to keep in mind that tobacco users move through stages of change in the process of quitting. They move from pre-contemplation to contemplation, contemplation to preparation; preparation to abstinence; abstinence to maintenance. Every stage requires a different strategy by a nurse.

After watching the video, and reflecting on the information presented, address each of the following questions.

1. What are the common symptoms associated with an exacerbation of COPD?
2. What assessment techniques will you use to assess Mary?
3. Identify smoking strategies that would be appropriate for each of the encounters that Mary had with the nurse throughout the video that could have been used to assist Mary in quitting smoking.
4. Find a resource in your community that could assist Mary. Start by searching the Internet for your local health department's website. What services are available to Mary? Briefly describe the services that the state quit line provides. Does it meet the 4 As? Is it accessible, acceptable, affordable, or available for Mary?
5. What will you do to follow-up on Mary's smoking cessation process?

Amira is a 27-year-old Syrian refugee who has been residing in a local homeless shelter since her arrival here in the United States 4 weeks ago. She was brought into the emergency room this morning via squad after being found by a shelter employee sitting in a pool of blood on the bathroom floor crying and holding her abdomen. Due to her limited English speaking abilities, she is unable to provide specific details as to her complaints but the shelter employee states that she has recently stopped eating and has not looked well for the past couple of days.

Based on the limited information provided, please answer the following questions.

1. How will you prioritize your care of Amira, what assessments will you complete, and in what order? Please provide rationale for choosing this order.
2. Are there any cultural beliefs/practices that must be taken into consideration when planning her care?
3. Considering her symptoms of abdominal pain and bleeding, is it possible that her status as a homeless refugee is a causative or contributing factor to her illness? Please provide rationale for your response.

Fred is an 83-year-old male who is being admitted to the medical-surgical unit status post fall. He is alert and oriented and reports that while visiting a local casino with his wife Margaret earlier this evening, he tripped over a curb and fell landing on his right side. After receiving morphine in the emergency room prior to transfer to your unit, Fred is rating his pain at 6/10. He has multiple bruises from his jawbone to his knee as well as a slight rotation of his right leg.

Past medical history includes: myocardial infarction (MI) x 2, peripheral vascular disease (PVD) with bilateral iliac stents, non-insulin-dependent diabetes mellitus (NIDDM), sleep apnea, and degenerative joint disease.

Medications include: aspirin, Plavix, Lopressor, Lisinopril, and Metformin.

After reviewing the above scenario please answer the following questions.

1. Based on the information provided, how will you prioritize your care, what assessments will you include and in what order? Please provide rationale for your response.
2. Considering this patient's age, injury, past medical history, and list of current medications, what, if any, concerns do you have related to his potential need for surgery?
3. Should surgery to repair his right femur be required; what type of clearance and pre-op orders would you anticipate receiving related to his diet, meds, lab work, and so on?

Please choose one of the patient scenarios below. Next, complete a rapid assessment, and provide a SBAR report to a classmate. Remember to include all concepts of patient safety, standard precautions, and professional standards.

1. You are covering for a coworker who is off the floor for lunch, when you suddenly hear a loud crash coming from a nearby patient room. You quickly run in and discover Mr. Johnson who was admitted yesterday with a diagnosis of cerebral vascular accident (CVA) unconscious on the floor between the bed and the bathroom.
2. You are called to the room of 2-year-old Jonah by his mother who states the child has suddenly started breathing very loudly and does not look right. Upon entering the room you quickly recognize that the child is in respiratory distress as his lips are cyanotic and the use of accessory muscles is evident.
3. You are in the process of admitting Ashley, a 27 year old who is 28 weeks pregnant with her first child, to the obstetric unit for complaints of headache, dizziness, and swelling of her lower extremities when she suddenly begins seizing.