Nursing Interventions and Care Protocols: Clinical Scenarios

Exc. 1 1. A man, 35 years old, diagnosedclosed Dextra crucis fracture, was hospitalized with complaints of pain in his legs since 1 day ago. The patient said the pain increased, especially when moved, with a pain scale of 6 (0-10). Examination results: the patient was grimacing in pain, swelling in the leg area, BP 150/90 mmHg, pulse rate 90x/minute, respiratory rate 26x/minute. Currently the patient has a splint installed from the metatarsal to the patella.What is the appropriate nursing intervention in this case? A. Recommend bed rest B. Teach relaxation techniques C. Apply a cold compress D. Collaborative administration of analgesics E. Observe the degree of discomfort Answer Key: D. Collaborative administration of analgesics Discussion:The first step in choosing the right nursing intervention for a patient is to determine the main problem the patient is experiencing. In this case the patient's main problem is pain on a scale of 6. Management of moderate-severe pain is prioritized using analgesic medication. 2. A man, 55 years old, was admitted to the hospital on day 2 post colostomy. The patient complained that his stool was full. Currently the nurse is carrying out colostomy care. The nurse has used gloves and then cleaned the stoma and the area around the stoma using sterile gauze. What next action should the nurse take in this case? A. Applying plaster B. Measuring the bag C. Applying ointment D. Fixing the bag E. Assess the condition of the wound Answer Key: C. Applying ointment Discussion:The colostomy care procedure begins with washing hands, opening the colostomy bag, assessing the condition of the stoma, cleaning the stoma, applying ointment, measuring the colostomy bag, installing the colostomy bag, tidying up the equipment and washing hands. 3. A man, 56 years old, diagnosed with pneumonia, was admitted to the hospital with complaints of shortness of breath since 3 days ago. The patient said his breathing felt heavy, he had no appetite, his fever fluctuated. Examination results: cyanosis of fingers and toes, BP 150/90 mmHg, pulse rate 110x/minute, respiratory rate 28x/minute, temperature 38oC, SaO293%, PaO272 mmHg, PaCO237 mmHg.What is the patient's primary nursing problem? A. Thermoregulation is ineffective B. Impaired gas exchange C. Ineffective breathing pattern D. Nutritional deficit E. Hyperthermia Answer Key: B. Gas exchange disorders Discussion:Pneumonia occurs due to bacterial infection in the alveoli, the alveoli become inflamed and secretions accumulate. This causes disruption of O gas exchange2and Co2which is indicated by the PaO value2or PCO2. Apart from that, nursing problems include gas exchange disorders characterized by major symptoms of dyspnea, tachycardia and cyanosis. 4. A woman, 37 years old, diagnosed with burns, was admitted to the hospital with complaints of pain in the burn area since 8 hours ago. Examination results: grade II burns with an area of 45%, BP 100/60 mmHg, pulse rate 64x/minute, respiratory rate 22x/minute, weight 60 kg. Currently the patient is given fluid therapyRL of 1500 cc.What are the criteria for the success of fluid therapy in this case? A. Urineoutput30-60 ml/hour B. Urineoutput60-90 ml/hour C. Urineoutput90-120 ml/hour D. Urineoutput120-150 ml/hour E. Urineoutput150-180 ml/hour Answer Key: A. Urine output 30-60 ml/hour Discussion:Determining the criteria for the success of fluid therapy uses the urine output formula = 0.5-1cc/kgBB/hour(0.5x60 kg=30 ml/hour and 1 x 60=60ml/hour). 5. A man, 40 years old, diagnosed with COPD, was admitted to the hospital with complaints of shortness of breath since 3 days ago. Examination results: rhonchi sounds, rapid and shallow breathing, nostril breathing, cyanosis of the fingertips, BP 100/70 mmHg, pulse rate 104x/minute, respiratory rate 30x/minute. The nurse determines the nursing problem: impaired gas exchange. What is the main supporting examination for this patient? A. Blood gas analysis B. Fluid electrolytes C. Whole blood D. Hemoglobin E. X-ray Answer Key: A. Blood gas analysis Discussion:The patient experiences problems with the respiratory system characterized by shortness of breath, cyanosis and rhonchi. Ronchi sounds appear because there is a buildup of secretions in the alveoli. This causes disruption of gas exchange and lack of O production2to the organs and periphery so that signs of cyanosis appear. To find out if there is a gas exchange disorder, a blood gas analysis is needed. 6. An elderly person, 60 years old, diagnosed with a stroke, was admitted to the hospital on the 3rd day. The patient said he was uncomfortable in the genital area where the catheter was installed. Examination results: dirty vaginal area, dirty area around catheter installation. At this time the nurse will carry out catheter care, the patient's position has been adjusted, the nurse washes her hands and puts on sterile gloves.What is the next step for the nurse to take? A. Clean the catheter tube from proximal to distal with a circular movement for ± 10 cm B. Clean the labia majora area using the principle of one gauze for one wipe C. Clean the labia minora area using the principle of one gauze for one wipe D. Clean the perineum area using the principle of one gauze for one wipe E. Observe the condition of the urethra and catheter patency Answer Key: C. Clean the labia minora area using the principle of one gauze for one wipe Discussion:When caring for catheters, especially in women, it is necessary to pay attention to vulva hygiene procedures because the steps taken after the nurse puts on sterile gloves are vulva hygiene with the following steps: 1. Clean the minora area using the principle of one gauze for one wipe. 2. Clean the majora area using the principle of one gauze for one wipe. 3. Clean the perineum area using the principle of one gauze for one wipe. 4. Then continue with stroking the catheter tube starting from proximal to distal of the catheter with a circular movement for ± 10 cm.