Question

Scenario 1: Cardiovascular CS 1 M.G., a “frequent flier,” is admitted to the emergency department (ED) with a diagnosis of heart failure (HF). She was discharged from the hospital 10 days ago and comes in today stating, “I just had to come to the hospital today because I can't catch my breath and my legs are as big as tree trunks.” After further questioning, you learn that she is strictly following the fluid and salt restriction ordered during her last hospital admission. She reports gaining 1 to 2 pounds every day since her discharge. The physician orders to start a PIV and give 80mg of furosemide IVP, place an indwelling foley catheter.

Scenario 2: Respiratory CS 18 You are working in the ED and B.A. is a 51-year-old woman who wishes to obtain a food handler's license and is required to show proof of a negative Mantoux (purified protein derivative [PPD]) test result before being hired. She came to the clinic 2 days ago to undergo a PPD test for TB. The clinic was closed so she decided to go to the ED to have her PPD read.

Scenario 3: You are working in the emergency department when M.B., a 72-year-old man, enters with a chief com-plaint of the inability to void. His initial vital signs (VS) are 168/92, 88, 20, 98.2° F (36.8° C).

1. Based upon the information given to you, what patient would you see first, second, third, and why?

2. What delegation could you give to your nursing assistant and/or assigned LPN?

3. Your priority patient, the one you will see first based on the scenario; what would be some potential complications you would be looking for throughout the day?

4. Next, on your priority patient write out in the nursing process your plan of care for your patient (ADPIE). What will be your focused assessment? What is your priority NANDA in three parts? Develop a plan and prioritize your interventions, minimum of three, and what would you want to see as the outcome or evaluation for your patient?

Answer 1

1. Based on the information given to you, what patient would you see first, second, third, and why?

From these three cases, I would give first priority to M.B who was at risk of urinary retention and increased blood pressure. Because retention of urine is due to stenosis, enlargement of the prostate, obstruction, or from tumors. His blood pressure is elevated and again prolonged urinary retention further elevates the blood pressure and leads to complication. The second priority gives to M.G who has cardiac problems and has peripheral edema. The Physician orders should be carried out to minimize the peripheral edema of the legs and to maintain normal hemodynamic status. The last priority gives to B.A because she just needs of reading the Mantoux test result which is not an emergency condition.

2. What delegation could you give to your nursing assistant and/or assigned LPN?

I assigned the LPN

• To collect a detailed history from the patient.
• Monitor the vital signs of the patient.
• Assign the LPN to insert a urinary catheter to the M.G

3. Your priority patient, the one you will see first based on the scenario; what would be some potential complications you would be looking for throughout the day?

The patient M.B has felt pain because of urinary retention. It is also difficult to insert a catheter because of bladder enlargement. The patient has a potential risk of the complication of bladder damage, acute kidney injury, and benign prostatic hyperplasia. So the patient has to monitor for B.P, elevated temperature, signs, and symptoms of infection, hematuria, level of pain, and palpable distension of the bladder.

4. Next, on your priority patient write out in the nursing process your plan of care for your patient (ADPIE). What will be your focused assessment? What is your priority NANDA in three parts? Develop a plan and prioritize your interventions, minimum of three, and what would you want to see as the outcome or evaluation for your patient?

Nursing Plan of Care

The care plan for M.B should be assessed properly and planning should be made based on the patient needs.

Focused Assessment:

• Assess the patient level of pain.
• Monitor vital signs
• Assess the bladder distension and level of comfort.
• Monitor the urine output and the color, odor, of urine.
• Monitor BUN.
• Scan the bladder.

Nursing Diagnosis:

• Urinary retention related to bladder obstruction as evidenced by decompensation of detrusor musculature.

Planning:

• Make the patient urinate a sufficient amount of urine.
• Empty the bladder thoroughly.

Intervention:

• Encourage the patient to void and assess the quantity and frequency of urine.
• Place the patient in an upright position to promote voiding.
• Perform Crede's maneuver to relax the sphincter muscles and promote voiding.
• Encourage fluid intake if not contraindicated.
• Calm the patient to minimize the anxiety level.

Evaluation:

Patient voided in sufficient amount and no palpable bladder distension.