Question

Ms. RG, 85 year old female

End-stage COPD Pressure Injury-Stage 3 PMH s/p right lobectomy x 1 year ago s/p trach placement

Vital Signs q 4 hours NPO Trach Care q shift and as needed Trach mask to 50% humidified O2 Wet to dry dressing to coccyx q shift Wound culture IV-D5 ½ NS @ 100mL/hour IV-Cefazolin 1g in 100 mL of D5W q 8 hours

CBC BMP PT, PTT Wound culture Diagnostic Test Na: 138mEQ/ L Cl: 90 mEQ/ L K: 4.0 mEQ/ L Cr: 1.2 mg/ dL Glucose: 200 mg/ dL BUN: 25 mg/ dL WBC: 6800/ mm/3 Hgb: 11.5 g/dL HCT: 34% PLT: 200000 PT- 18 aPTT: 25 seconds

Patient had restful shift; needs dressing change to pressure injury on coccyx. Planned transfer back to SNF tomorrow.

1. What clinical assessment data did you just collect that is relevant and needs to be trended because it is clinically significant to detect a change in status?

2. Does your nursing priority or plan of care need to be modified in any way after assessing your patient?

3. After reviewing the primary care provider’s note, what is the rationale for any orders or changes made?

4. What educational priorities have you identified?

5. What is the patient likely experiencing or feeling right now in the situation?

Answer 1

Q. No. 1. Answer :

Clinical assessment data should be collect here include, first vital signs are important because patient is in chronic copd state and aged and bed ridden.

* vital signs like temperature, pulse, respiration, blood pressure is important to monitor because there may be a temperature raised, and tachycardia and tachypnea, and saturation levels also monitor.

* collect history regarding diabetis and hypertension.

* because client sugar levels are 200 mg per dl.

* regarding ryles tube and Foley catheter also collect the information.

Q. No. 2. Answer :

After assessing the client nursing care plan is prepared depending upon priority based.

* According to the needs of the client nursing care plan has to prepare, first give importantance for emergency problems like breathing, next reduce pain, temperature, nutritional requirements, fluid requirementa, dressing to the pressure ulcers, maintainance of aseptic conditions ect.

Q. No 3. Answer :

After reviewing the primary care provider note, the administration of dextrose water should be charged, because here the client glucose levels are increasing that is 200 mg per dl.

* along with dressing to the pressure ulcer we need to provide water bed or alpha bed to the client.

* position changing 2 nd hourly.

* nutritional supplementation through rules tube.

* maintainance of intake and output chart.

Q. No. 5. Answer :

Patient feeling in this situation :

Client may feel in this situation like no need any treatment and she need peaceful death, because being aged and chronic disease and with ulcers she don't want to feel this much pain.

So she feels she want hospice care.