Question

Group 2 You are assigned to care for a 72-year-old woman with severe emphysema. Today she was walking at a mall when she suddenly grabbed her right side and gasped, Oh, something just popped. She whispered to her walking companion, "I can't get any air." Her companion yelled for someone to call 911 and helped her to the nearest bench. By the time the rescue unit arrived, she was stuporous and in severe respiratory distress. She was intubated, started on intravenous lactated Ringer's at KVO (keep vein open). and transported to the nearest emergency department (ED). On arrival at the ED, you auscultate muffled heart tones, no breath sounds on the right, and faint sounds on the left. She is stuporous, tachycardiac and cyanotic. The paramedics inform you that it was difficult to ventilate her. A portable chest x-ray (ORI examination shows an 80% pneumothorax on the right. Arterial Blood Gases (ABGs) on 100% O2: pH 7.25 Paco2 92 mm Hg Pao2 32 mm Hg HCO3 27 mmol/L SpO2 53% 1. What are the most important areas you need to evaluate during your physical assessment? 2. Interpret the ABGs 3. What is the reason for the ABG results? 4. It is now the end of your shift and her condition has stabilized. Using the SBAR framework, describe the bedside change-of-shift report you will give the oncoming nurse. 5. What are some appropriate nursing diagnoses for this client? 6. What are some nursing interventions that you would provide based on the above lab values? Search entries or author Unread c: Week 4...+.. oom galencollege.edu/courses/2444271/discussion topics/1Read

Answer 1

1. The important areas of physical assessment are :-

- Vital signs including temperature,heart rate, respiratory rate ,blood pressure

- cyanosis (central)

- shortness of breath

- air hunger

- use of accessory muscles

- pleuritic pain

- diaphoresis

- tachycardia and hypotension

2. According to the given ABG values, it indicates respiratory acidosis because there is increase in pCO2 (92mmhg) which is more than normal range 35 - 45mmhg , pH is (7.25 )below normal range 7.35 - 7.45 which indicate acidosis and pO2 is 32 which is below normal range 80 -100 mmHg . It is occurring due to impaired lung function and retention of CO2 in lungs and blood .

3. The reason for respiratory acidosis is impaired lung function and retention of CO2 in lungs and blood stream .

4. SBAR framework is a acronym for situation , background , assessment and recommendation . It is a technique used to facilitate appropriate communication .

SBAR framework for change of shift :-

1.Situation - include details of present date , diagnosis , admission date , patients sticker , and provider pager.

2.Background - includes details of medical history of patient , allergies ,code status ,current treatment, fall prevention and restraint precautions

3.Assessment includes:-

- neurological assessment( GCS , REFLEXES etc)

- cardiac assessment(heart rate, blood pressure etc)

- GI assessment(bowel sounds etc)

- musculoskeletal assessment

- skin assessment including (any dressing due , pressure sores etc)

- psychosocial assessment

- X - ray results

- abnormal lab values

- lines and fluids

- IV line and dressing (any due )

- Last vital signs including temperature ,heart rate , respiratory rate , blood pressure and pain scale

4.Recommendation includes :-

- Goals (planned intervention and results)

- Tests / Treatment

- Consultation

- Discharge needs