Question

Time Evaluation and Priority Setting Lisa Jones, 88 year-old, was admitted to the unit from surgery yesterday, after having a cardiac catherization with PCI. Lisa's history includes chronic atrial flutter, Krinary incontinence, und diabetes mellitus. During the night, she pulled her urinary catheter and IV catheter out. The night nurse reported to you that the IV catheter and Foley catheter would need to be replaced. The nurse explains that there was a cardiac emergency on the unit which has delayed the Foley and IV being replaced. The patient complaints that she has pain/discomfort in the rectum and is very upset at the night staff because they don't care about patient's and are rude. After she stops yelling and has calmed down, she informed you that she has pain in her left calf. During assessment, the nurse notes that the area is warm, reddened and tender to touch. Doctors Order: 1. Baseline Partial Thromboplastin time, International Normalized Ration, Platelet count, Hemoglobin and hematocrit 2. Repeat PTT per heparin protocol (every 6 hours at first) 3. Chest radiograph 4. Intravenous heparin per protocol 5. Elevate and apply heat to affected extremity Directions: 1. What are the focus areas of assessments? 2. Determine the priority after performing the assessment. 3. Use the Time log provided to plan your activities in order of priority.

Answer 1

1. The focused area of assessment for Lisa Jones are

• Cardiovascular and peripheral vascular system
• Musculoskeletal system
• Renal system
• Skin for change of color, temperature.

2. The priority of needs of Lisa Jones are

• Monitor vital signs to know the baseline data.
• Assess the level of pain in the left calf muscles.
• Take the blood sample and send to the lab as per physician orders.
• Assess the left leg skin for redness, warmth, tenderness and elevate the part to Prevent DVT.
• Apply heat to the affected part.
• Assess the cardiac cath site for bleeding, oozing, and swelling.
• Insert a new IV line.
• Once the PTT report collected administer heparin as per protocol.
• Assess urinary incontinence and insert a foley catheter
• Take chest radiograph.
• Change of position q2H.
• Repeat PTT every 6 hours

3. Time Log for the planned activities

8 00 am Monitor vital signs

8 10 am Send blood samples to the Lab.

8 15 am Assess the left leg for DVT and elevate the part.

8 20 am Apply heat to the affected area.

8 25 am Assess the cardiac cath site for bleeding, oozing, and swelling.

8 30 am Insert new IV line and administer heparin.

8 40 am Assess for urinary incontinence and insert foley's catheter.

9 00 am Take chest X-ray

10 00 am Change of position

2 00 pm Repeat PTT