Order Primary care provider’s orders vs primary problem relationship essay assignment
Primary care provider’s orders vs primary problem relationship essay assignment
Cerebral Vascular Accident (CVA)
John Gates, 59 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis) 1. Stress
2. Coping
3. Clinical Judgment
4. Patient Education
© 2016 Keith Rischer/www.KeithRN.com
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FUNDAMENTAL Reasoning: STUDENT Cerebral Vascular Accident (CVA)
History of Present Problem: John Gates is a 59-year-old male with a history of diabetes type II and hypertension who was at work when he had sudden
onset of right-sided weakness, right facial droop, and difficulty speaking. He was transported to the emergency
department (ED) where these symptoms continue to persist. It has been one hour from the onset of his neurologic
symptoms when he presents to the ED. You are the nurse responsible for his care.
Personal/Social History: John lives with his wife in their own home in a small rural community. He owns a hardware store where he remains
active and involved in the day-to-day operations. His wife insists on being by his side and talking to John despite John’s
frustration in not being able to answer her questions. His wife reports that the past week he has been complaining of
episodes where his heart felt as if it was beating irregularly and fast but then resolved. His wife also states that he has been
complaining of pain in his right foot the past week. John has been trying to quit smoking the past month and has been
using a nicotine patch. His wife reports that he does not regularly check his blood glucose and eats what he wants. He is 6
feet tall and weighs 250 pounds (113.6 kg/BMI of 33.9).
What data from the histories are RELEVANT and has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
RELEVANT Data from Social History: Clinical Significance:
Developing Nurse Thinking by Identifying Significance of Clinical Data Patient Care Begins:
What VS data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS data: Clinical Significance:
Current VS: P-Q-R-S-T Pain Assessment: T: 99.2 F/37.3 C (oral) Provoking/Palliative: Unable
P: 118 (irregular) Quality:
R: 20 (regular) Region/Radiation:
BP: 198/94 Severity:
O2 sat: 99% room air Timing:
© 2016 Keith Rischer/www.KeithRN.com
What assessment data are RELEVANT and must be recognized as clinically significant to the nurse?
RELEVANT assessment data: Clinical Significance:
Developing Nurse Thinking through APPLICATION of the Sciences Fluid & Electrolytes:
Lab/diagnostic Results:
Radiology Reports: Head CT What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT Results: Clinical Significance: No abnormalities noted,
no mass, no bleed, no
shift present
Lab Results:
Current Assessment:
GENERAL
APPEARANCE:
Appears anxious–he is aware and appears to be concerned about changes in neuro status.
RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort
CARDIAC: Pink, warm & dry, no edema, heart sounds irregular–S1S2, telemetry rhythm is atrial
fibrillation, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Is anxious, restless, and agitated, speech is currently slurred and difficult to understand, facial droop present on right side, pupils equal and reactive to light (PEARL), both right
upper extremity (RUE) and right lower extremity (RLE) notably weak (3/5) in comparison to
left, which is strong (5/5), right pronator drift present, unable to hold right arm up, right
visual deficit cut present
GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants
Able to swallow saliva
GU: Voiding without difficulty, 700 mL urine clear/yellow,
SKIN: Skin integrity appears intact, right foot not assessed at this time
Complete Blood Count (CBC) Current High/Low/WNL? Previous:
WBC (4.5-11.0 mm 3) 6.8 7.9
Hgb (12-16 g/dL) 14.8 16.1
Platelets(150-450x 103/µl) 228 201
Neutrophil % (42-72) 71 79
© 2016 Keith Rischer/www.KeithRN.com
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:
Lab Planning: Creating a Plan of Care with a PRIORITY Lab:
Lab: Normal
Value:
Why Relevant? Nursing Assessments/Interventions Required:
Creatinine
Value:
1.5
RED FLAG:
Pharmacology: Home Med: Classification: Mechanism of Action
(in own words): Nursing Considerations:
Indomethacin
Aspirin
Basic Metabolic Panel (BMP) Current High/Low/WNL? Previous:
Sodium (135-145 mEq/L) 133 139
Potassium (3.5-5.0 mEq/L) 4.1 4.5
Glucose (70-110 mg/dL) 222 128
Creatinine (0.6-1.2 mg/dL) 1.5 1.1
Coag
PT/INR (0.9-1.1 nmol/L) 1.1 n/a
© 2016 Keith Rischer/www.KeithRN.com
Lisinopril
Simvastatin
Metformin
Pathophysiology: 1. What is the primary problem that your patient is most likely presenting?
2. What is the underlying cause/pathophysiology of this primary problem?
(Relate initial manifestations to the pathophysiology of the primary problem)
Pathophysiology of Primary Problem: Rationale/Relationship to Manifestations:
Developing Nurse Thinking by Identifying Clinical RELATIONSHIPS 1. What is the RELATIONSHIP of the past medical history and current medications?
(Which medication treats which condition? Draw lines to connect)
Past Medical History (PMH): Home Meds:
Diabetes mellitus type II-poorly controlled
Hypertension
Hyperlipidemia
Gouty arthritis
Smokes 1 ppd x 40 years
Lisinopril
Indomethacin
Aspirin
Metformin
Simvastatin
2. Is there a RELATIONSHIP between any disease in PMH that may have contributed to the development of the current problem? (Which disease likely developed FIRST then began a “domino effect”?)
PMH: What Came FIRST:
Diabetes mellitus type II-poorly
controlled
Hypertension
Hyperlipidemia
Gouty arthritis
Smokes 1 ppd x 40 years
What then followed:
© 2016 Keith Rischer/www.KeithRN.com
3. What is the RELATIONSHIP between the primary care provider’s orders and primary problem?
Care Provider Orders: How it Will Resolve Primary Problem/Nursing Priority:
Establish peripheral IV
12 lead EKG stat
Labetalol 10-20 mg IV prn every 15
minutes to keep SBP 160-180
CT head stat
Cardiac monitor continuous
NPO
Alteplase IV dose per pharmacy
(if CT negative for bleed)
Developing Nurse Thinking by Identifying Clinical PRIORITIES 1. Which Orders Do You Implement First and Why?
Care Provider Orders: Order of Priority: Rationale:
1. Establish peripheral IV
2. Labetalol 10-20 mg IV prn every 15″ to keep SBP
160-180
3. CT head stat
4. Cardiac monitor continuous
5. Alteplase IV (if CT negative for bleed)
© 2016 Keith Rischer/www.KeithRN.com
2. What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY)
3. What interventions will you initiate based on this priority?
Nursing Priority: Nursing Interventions: Rationale: Expected Outcome:
4. What are the PRIORITY psychosocial needs that this patient and/or family likely have that will need to be addressed?
5. How can the nurse address these psychosocial needs?
6. What educational/discharge PRIORITIES will be needed to develop a teaching plan for this patient and/or family?
Caring & the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation?
2. What can I do to engage myself with this patient’s experience, and show that he/she matters to me as a person?
Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention
in the moment as the events are unfolding to make a correct clinical judgment and transfer what is learned to improve
nurse thinking and patient care in the future.
1. What did I learn from this scenario?
2. How can I use what has been learned from this scenario to improve patient care in the future?