Question

KB 32 year old female

c/o fatigue, nausea x 2days, severe diarrhea and dehydration; DM-Insulin dependent since age 8; Hemodialysis (HD) for the past 2 years for ESRD. AV fistula in her left arm

NPO Epoetin 3 x/week with dialysis Nephrocaps vitamin supplement daily

Labs on admission- Na 145mEq/L K 6.0 mEq/L Chloride 93 mEq/L BUN 48 mg/dL Cr 5.0mg/dL Glucose 238 mg/dL CBC WBC 7600/mm3 RBC 3.2 million/mm3 Hgb 8.1g/dL Hct 24.3% Platelets 333000/mm3 Vital signs on admission 140/88, HR 116, RR 18, T-99.9

1. What is the primary problem and what is its underlying cause or pathophysiology?

2. What clinical data from the chart is relevant and needs to be trended because it is clinically significant?

3. List all relevant nursing priorities. What nursing priority captures the essence of your patient’s status and will guide your plan of care?

4. What nursing interventions will you initiate based on this priority and what are the desired outcomes
5. What body system(s), key assessment and psychosocial needs will focus on based on your patient’s primary problem or nursing care priority?
6. What is the worst/most likely complication(s) to anticipate based upon the primary problem?
7. What nursing assessments will identify this complication early if it develops?
8. What nursing interventions will you initiate if this complication develops?

Answer 1

1. ANS:

Typically going to be the admission medical problem of diagnosis.

Be able to truly UNDERSTAND the pathophysiology of the illness or the patient's problem.

Recognizing the clinical relationship and establishing correct nursing care priorities.

2. ANS: Filter clinical data and focus on what is RELEVANT to trend.

3. ANS: I should be able to identify at least five relevant care priorities. i.e., COPD
- fatigue
- anxiety
- activity intolerance
- impaired gas exchanged
- self-care deficit
- risk for impaired skin integrity

Two approaches to determine priority
- ABC's
- Identify the relationships between the listed care priorities.

4. ANS: Identify the RATIONALE for every intervention that is implemented. Correctly stating the rationale ensures safe practice.

6. ANS: It can make a difference in improving patient outcomes.

7. ANS: Once the worst possible/most likely complication is identified, the specific assessment to recognize it correctly must be determined. This is essential to good patient outcomes.