Question

Go to Clinical Case

After reviewing the “Go to Clinical Case” complete the questions below and bring to class on Wednesday November 13^th. In class you will compare your priority assessments/cues and nursing interventions/actions with another student and how your lists are similar and/or different.  In addition, you will give and receive hand-off SBAR report with another student and provide feedback. State 3 things that were good and 3 areas of improvement regarding the SBAR report.

Deborah Smith is an 80-year old with heart failure and hypertension. Her son brings her to the emergency room department because she has become increasingly weak and confused. She has a moist cough that has gotten worse and she has had increasing difficulty breathing.  Deborah’s son says he noticed that his mom seems to be gaining a lot of weight and her ankles are “huge.” Deborah takes lisinopril, losartan, and furosemide. She is admitted to the hospital with fluid volume excess.

Clinical Judgement Challenge - for each student

1. What are the Top 3 priority assessments or cues for Deborah?

1.

2.

3.

2. What are the Top 3 priority nursing actions for Deborah?

1.

2.

3.

3. Develop a hand-off report and bring to class.

Clinical Judgment Challenge - for Small Groups      

4. Compare your priority assessments/dues and nursing interventions/actions with another student. How were your lists similar and/or different?
5. With another student, give and receive report. Provide feedback to the other student.  

Answer 1

Top 3 priority Assessment.

1.Respiratory Assessment:Assess the breathing pattern, saturation, respiratory rate,use of accessory muscles for breathing,cough productive or dry .

2.Cardiac Assessment:Assess the patients blood pressure,lower extremities for pitting edema,urinary output,

3.Neurilogical Assessment:Assess the patients consiusness,GCS,drowsy or arousable,limb strength , orientation to time place and person.

The Assessment should be followed by a laboratory workup on electrolytes.

Top 3 Nursing Intervention

1) Adminster oxygenation using nasal prongs,or face mask .if needed use of bipap.

2)cardiac monitoring,ask for a chest x-ray to determine pulmonary edema

2) Catherization of the patient with Foley's to track intake output.restrict the fluid intake .

3)Adminster diuretics to maintain a negative balance

4) nebulization or steam inhalation to loosen the cough to aid in breathing .

5)keep the intubation trolley ready as she is drowsy.

Hands off report

The handoff report should be in SBAR format

S:Hi this is xyz nurse handing over Ms Smith 80 years female admitted in Emergency department with complaints of being weak ,drowsy and difficulty in breathing.

B :Ms Smith is known case of Hypertension and heart failure with productive cough .she is on tablet lisnopril,losartan and furesemide

A:On Assessment it's found that Ms Smith has difficulty in breathing and is confused.she has pitting edema in ankles .I think she is fluid overload

R:I want you to check on her breathing and start on non invasive ventilation,level of consciousness and if needed go ahead for mechanical ventilation.i want you to cathetrize the patient to get a tract of output .she will need cardiac monitoring and lab workup to be done immediately.