Covid-19 Skinny Reasoning pt 2

Novel Coronavirus Disease (COVID-19) Part II: Admission to MedSurg SKINNY Reasoning John Taylor, 68 years old Primary Concept Immunity/Gas Exchange Interrelated Concepts (In order of emphasis) • Clinical judgment • Communication NCLEX Client Need Categories Safe and Effective Care Environment • Management of Care • Safety and Infection Control Health Promotion and Maintenance Psychosocial Integrity Physiological Integrity • Basic Care and Comfort • Pharmacological and Parenteral Therapies • Reduction of Risk Potential • Physiological Adaptation Covered in Case Study ✓ ✓ ✓ ✓ ✓ ✓ ✓ NCSBN Clinical Judgment Model Step 1: Recognize Cues Step 2: Analyze Cues Step 3: Prioritize Hypotheses Step 4: Generate Solutions Step 5: Take Action Step 6: Evaluate Outcomes Covered in Case Study ✓ ✓ ✓ ✓ ✓ ✓ Part: II: Admitted to Med/Surg John Taylor is stabilized in the emergency department and will be admitted to your Med/Surg unit for observation with a diagnosis of COVID-19. You receive the following SBAR report in preparation to assume care: SBAR Handoff to MedSurg Nurse: Situation: Name/age: John Taylor is a 68-year-old African-American male BRIEF summary of primary problem: He presented to the emergency department because he felt crummy; complaining of a headache, runny nose, feeling more weak, “achy all over” and hot to the touch and sweaty the past two days. When he woke up this morning, he no longer felt hot but began to develop a persistent “nagging cough” that continued to worsen throughout the day. He has difficulty “catching his breath” when he gets up to go the bathroom. Background: Primary problem/diagnosis: positive for COVID-19 RELEVANT past medical history: hypertension and type II diabetes Code status: Full code Assessment: Most recent vital signs: • T: 100.6 F/38.8 C (oral) • P: 112 (regular) • R: 18 (regular) • BP: 142/84 MAP: 103 • O2 sat: 93% 2 liters n/c RELEVANT body system nursing assessment data: GENERAL SURVEY: Appears anxious, body tense and is sitting upright in bed RESPIRATORY: Breath sounds fine dry crackles bilat. with diminished aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, non-labored respiratory effort, episodic non-productive cough RELEVANT lab values: • WBC: 3.5/ Neuts: 84%/ Lymphs: 11%/ Bands: 5% • Creat: 1.10 • Influenza: Neg/ COVID-19: Pos/ Lactate (Ven): 2.1 How have you advanced the plan of care? I have maintained strict contact and droplet precautions and have been closely monitoring his vital signs and respiratory status. Patient response: John understands his current condition and his questions have been answered. He presented to the emergency department on room air and was 92%, but his O2 sat dropped slightly in the last hour to 91%. He was placed on 2 L per nasal cannula and his O2 sat has been consistently 93% with no shortness of breath at rest. INTERPRETATION of current clinical status (stable/unstable/worsening): His current condition is stable. Recommendation: Suggestions to advance the plan of care: John will require ongoing monitoring and assessment of his vital signs and respiratory status to identify changes if he begins to decline. 1. After receiving SBAR report, in one sentence describe the ESSENCE of the patient problem that will guide your plan of care. (NCLEX: Management of Care) Admitted to Med/Surg: Fifteen Minutes Later… John is transferred to the med/surg unit and you are the nurse responsible for his care. After introducing yourself, you collect the following clinical data: Current VS: Most Recent in ED: T: 101.2 F/38.8 C (oral) P: 120 (regular) R: 24 (regular) BP: 122/68 MAP: 86 O2 sat: 94% 2 liters n/c T: 100.6 F/38.8 C (oral) P: 112 (regular) R: 20 (regular) BP: 152/84 MAP: 107 O2 sat: 93% 2 liters n/c Current PQRST: Provoking/Palliative: Quality: Region/Radiation: Severity: Timing: “moving makes it worse” “achy” “all over” 5/10 continuous 2. What VS data are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: TREND: Improve/Worsening/Stable: 1) PR: 120 2) BP: 120/68 hypotensive 3) Pain: 5/10 4) Temp if 101.2 1) Pt is tachycardic, mot likely due to pain. Monitor and see if there is improvement after given pain relief 2) BP dropped from 152/84 to 120/68 3) Pt needs to be offered medication or nonpharmalogical techniques to help relieve pain 4) Needs fever reducer 1) Pulse is increasing/ worsening 2) BP has dropped from too high to too low 3) Not improving 4) Temp is increasing/ worsening Current Head to Toe Nursing Assessment: GENERAL SURVEY: Appears anxious, body tense and is sitting upright in bed NEUROLOGICAL: Alert & oriented to person, place, time, and situation (x4), nods head and uses gestures to avoid talking. Generalized weakness. HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and moist. Breath sounds light crackles bilat. with diminished aeration on inspiration and expiration in RESPIRATORY: all lobes anteriorly, posteriorly, and laterally, slightly labored respiratory effort, persistent non-productive cough. CARDIAC: No edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. ABDOMEN: Abdomen round, soft, and nontender. BS active in all 4 quadrants, has no appetite. GU: Reports last void was appx. three hours ago. No pain or burning with urination. INTEGUMENTARY: Skin hot, dry, intact, normal color for ethnicity. Skin integrity intact, skin turgor elastic, no tenting present. 3. What assessment data is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential Reduction of Risk Potential/Health Promotion & Maintenance) RELEVANT Assessment Data: Clinical Significance: TREND: Improve/Worsening/Stable: 1) Appears anxious, body tense 2) Breath sounds bilat light crackles 3) Slightly labored resp effort 4) Persistant non-prod cough 5) No appetite 6) Has not voided in 3 hr 1) Objective symptom of pain 2) Fluid / mucous in lungs 3) Pt is exxperiencing difficulty breathing with O2 4) Pt need to be offered anttussive medication 5/6) Offer liquids to help with pt hydration urination/ avoid weakness 1) Has not improves 2) Worsening 3)Worsening 4) Worsening 5/6) Worsening 4. What is the pathophysiology of the priority problem? (NCLEX: Management of Care/Physiologic Adaptation) Priority Problem: Impared gas exchage due to diagnosis of Covid-19, related to resp problems he’s experiencing Pathophysiology of Problem in OWN Words: Covid-19 virus causes a build up in the resperatory tract, making it hard or nealy impossible for O2 and CO2 to be exchanged in the alveoli and capilaries, due to the blockage of fluids. This results in the SOB, crackles in lungs, non-productive cough, and labored breathing. Collaborative Care: Medical Management 5. State the rationale and expected outcomes for the medical plan of care. (NCLEX: Pharm. and Parenteral Therapies) Care Provider Orders: Rationale: Expected Outcome: Enhanced droplet/contact Prevent the spread of pathogens through resp Prevent precautions secreation and spreading of COVID-19 contamination / spread of covid Acetaminophen 650 mg PO every 4 hours PRN temp < 101 F/38.3 C Fever reducer, while also aid in relieving body ache and muscle pain Reduced pain and fever VS during preferred care times only and PRN if change in condition. Overnight VS not necessary unless change in condition. VS should be monitored to see if they have improved or worsened so we know if our implementations are working. VS within normal ranges, or improcing O2 to maintain O2 sat >90% Limit 8 LPM O2 via oxymask in droplet precautions. O2 needs to increase within normal ranges, above or equal to 95% while also avoiding hypoxemia Maintain his O2 levels and make sure he is recieving adequate amount of O2 Telemetry will monitor heart rhythms that will show if he is at risk for HF Check )2 levels to see whether or not it is improving or if adjustments need to be made to O2 Make sure he has no heart problems Improved O2 >8 LPM O2 per oxymask-place on airborne precautions. Telemetry – cardiac monitor Continuous oximetry 6. What nursing priority (ies) and goal will guide how the nurse RESPONDS to formulate a plan of care? (NCSBN: Step 4 Generate solutions/Step 5: Take action/NCLEX: Management of Care) Nursing PRIORITY: Impaired gas exchange GOAL of Care: Pt will be able to maintain adequate O2 and breathing patterns Nursing Interventions: Adminsiter O2 per oxymask Rationale: Pt will recieve the O2 they need to reach adequate levels so that they will be able to breath better and feel more comfortable. This will help to avoid any medical emergencies. Oxymask is to be used to help prevent spread of pathogens of Covid 19. Expected Outcome: Pt O2 level will be increased to at least at 95%-100% Caring and the “Art” of Nursing 7. What is the patient and spouse likely experiencing/feeling right now in this situation? What can you do to engage yourself with this patient’s experience, and show that they matter to you as a person? (NCLEX: Psychosocial Integrity) What Patient is Experiencing: How to Engage: Anxiety and fear of having Covid-19 because of the death rates, and also due to the fact that he is experiencing troubles breathing along with being in pain. Being an active listener to this patient and asking open ended questions to help to see how he is handling the situation within himself. This will help to form a trusting nurse to patient bond and hopefully can help to comfort this patient emotionally. The patient will also be informed right away of any tests to be done, results or changes with an explanation. Reflect on Your Thinking to Develop Clinical Judgment 8. To develop clinical judgment, reflect on your thinking that was used to complete this case study by answering the following questions: What did you do well in this case study? What weaknesses did this case study identify? Identifying the nursing priorities of this patient. Knowledge of the pathophysiology that this diagnosis of Covid does to the respiratory tract all the way down to the aveoli and capillaries. What is your plan to make any weakness a strength? How will you apply what was learned to future patients? RESEARCH, just as I did, I will need to do more research especially because Covid 19 is a new normal in nursing I will be able to educate them if they have any questions of their Covid diagnosis.