History of Present Problem: Elena Acosta is a 54-yr. old Hispanic…

Question Answered History of Present Problem: Elena Acosta is a 54-yr. old Hispanic… History of Present Problem: Elena Acosta is a 54-yr. old Hispanic woman with hypertension managed with hydrochlorothiazide. She is 63″ (160.2 cm) and weighs 175 pounds (79.3 kg-BMI 31.0). She felt “crummy” and weaker the last 24 hours and called 911 when she began to have mid-sternal chest pain that increased with coughing and developed a harsh productive cough with green phlegm with difficulty breathing. Initial lab results: WBC 14.5, neutrophils 92%, Hgb 12.9, potassium 3.5, creatinine 1.1, total bili 0.9, ALT 42, chest x-ray revealed RLL infiltrate consistent with pneumonia, blood and sputum cultures collected and pending. Smell of ETOH present on her breath. Blood alcohol level 0.04, urine drug screen negative. She is admitted to the medical unit with a diagnosis of pneumonia. You are the nurse responsible for her care. Personal/Social History: Ms. Acosta works in a mid-level management position for a corporate finance company. She describes her job as quite stressful. She drinks 4-5 cups of coffee every day and to least 1-2 alcoholic drinks most days. She states that she shouldn’t smoke and has cut down to about 1?2 a pack per day. She reports drinking more and sleeping poorly following her father’s death over a year ago. She takes alprazolam as needed for sleep or when she feels more anxious. She is hesitant to be admitted because she has a high deductible insurance plan and doesn’t know how she will be able to afford it. What data from the histories are RELEVANT and have clinical significance to the nurse? (Reduction of Risk Potential) 1.RELEVANT Data from Present Problem and clinical significance: 2. RELEVANT Data from Social History and clinical significance: Patient Care Begins: Initial Assessment Medical Unit Current VS: T: 101.2 F/38.4 C (oral) P: 96 (regular) R: 28 (regular) BP: 138/88 O2 sat: 92% room air P-Q-R-S-T Pain Assessment: Provoking/Palliative: Quality: Region/Radiation: Severity: nothing ache Denies chest pain currently/Headache-global 5/10 constant Timing: What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) 1.RELEVANT VS Data and clinical significance: Current Assessment: GENERAL SURVEY: Looks older than stated age, alert, oriented, pleasant, in no acute distress, calm, body relaxed, no grimacing, appears to be resting comfortably. NEUROLOGICAL: Alert & oriented to person, place, and situation (x3), knew year, but wrong day of week, feels fatigued with chills, weak, no focal deficits 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. RESPIRATORY: Breath sounds bibasilar crackles posteriorly, diminished aeration R>L bases, nonlabored respiratory effort on room air, productive cough with moderate amount thick yellow/brown tinged sputum CARDIAC: Pink, warm & dry, 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-E-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. ABDOMEN: Abdomen round, soft, and nontender. BS + in all 4 quadrants GU: Voiding without difficulty, urine clear/yellow INTEGUMENTARY: Skin warm, dry, intact, normal color for ethnicity. No clubbing of nails, cap refill <3 seconds, Hair soft-distribution normal for age and gender. Skin integrity intact, skin turgor elastic, no tenting present. What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion & Maintenance) 1. RELEVANT Assessment Data and clinical significance: Unfolding: Day #2 at 0100... The nurse finds Ms. Acosta fully awake. Reports she was starting to feel better because she was able to rest and eat a little food. Now she feels worse again, but in a "different way". The nurse completes a focused respiratory assessment and general health assessment. Review the following reported signs and symptoms. Current VS: T: 99.0 F/37.2 C P: 110 (reg) R: 20 (reg) BP: 154/92 O2 sat: 95% RA 4 Hours Ago: T: 98.6 F/37.0 C P: 98 (reg) R: 20 (reg) BP: 136/84 O2 sat: 94% RA Current PQRST: Provoking/Palliative: Bright lights make pain worse Quality: Throbbing like an elastic band around my head Region/Radiation: headache Severity: 7/10 Timing: Constant What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) 1.RELEVANT VS Data and clinical significance: Current Assessment: GENERAL SURVEY: Dressed in hospital gown; appears uncomfortable; restless; constantly repositioning self in bed NEUROLOGICAL: Alert & oriented to person, and place, did not know where she was or the day of the week; moderate hand tremors when asked to extend both arms 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. RESPIRATORY: Breath sounds clear with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort; O2 sat: 95% on room air or oxygen? CARDIAC: Pink, warm & dry, 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-E-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. ABDOMEN: Abdomen round, soft, and nontender. BS + in all 4 quadrants, no appetite, upset stomach with nausea; no vomiting GU: Voiding without difficulty, urine clear/yellow INTEGUMENTARY: Forehead moist, skin warm, and intact, normal color for ethnicity. No clubbing of nails, cap refill <3 seconds, Hair soft-distribution normal for age and gender. Skin integrity intact, skin turgor elastic, no tenting present Mental Status Examination (MSE): APPEARANCE: Moderately overweight woman; Looks fatigued and anxious. Less willing to answer assessment questions currently "Just leave me alone, please". Disheveled appearance. Reports currently having difficulty sleeping MOTOR BEHAVIOR: Moderate hand tremor when asked to extend arm twitching, reports feeling shaky inside, frequent repositioning noticed SPEECH: Normal rate and rhythm; occasionally slow to respond MOOD/AFFECT: c/o fatigue and mild depression; intense anxiety; 7 out of a possible 10; irritable and tearful at times THOUGHT PROCESS: Linear and logical THOUGHT CONTENT: Preoccupied with physical symptoms; no evidence of delusions PERCEPTION: Denies hallucinations; reports being bothered by bright lights and noise of the unit INSIGHT/JUDGMENT: Difficult to assess at this time; continues to recognize need for hospitalization for symptoms of pneumonia; seems to understand drinking as a coping strategy for increased stress and not a problem by itself COGNITION: Generally oriented but date is off by 2 days SUICIDAL/HOMICIDAL: Denies suicide, homicide or self-harm ideation What clinical data are RELEVANT that must be recognized as clinically significant? (Reduction of Risk Potential/Health Promotion and Maintenance) 1.RELEVANT Assessment Data and clinical significance: RELEVANT MSE Assessment Data: Clinical Significance: Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? (Management of Care, Physiological AdaptationEvaluation of Current Status: Modifications to Current Plan of Care: Clinical Reasoning Continues... Interpreting relevant clinical data, what is the "new" primary problem? What primary health related concepts does this primary problem represent? (Management of Care/Physiologic Adaptation) Problem: Pathophysiology of Problem in OWN Words: Primary Concept: 2.Based on your current evaluation, what are your CURRENT nursing priorities and plan of care? (Management of Care) CURRENT Nursing PRIORITY: PRIORITY Nursing Interventions: Rationale: Expected Outcome: In response to the assessment and recommendations of the nurse, the primary care provider orders the following: Collaborative Care: Medical Management (Pharmacologic and Parenteral Therapies) Provide rational for each order and expected outcome. Care Provider Orders:Lorazepam 2 mg now. Lorazepam 1 mg by mouth (PO) every 4 hours x 2 days. Lorazepam 1 mg PO q 1 hr. for breakthrough withdrawal symptoms (elevated CIWA scores). Hold and notify provider for sedation prior to dose.Max dose of 12 mg per 24 hours. Thiamine 1100 mg PO/IV/IM Q8H/TID x 3 days, then 100 mg. PO daily Folic acid 1 mg daily PO Multivitamins 1 tab daily by mouth CIWA scale every 4 hours with VS every 4 hours and PRN as clinically indicated Seizure precautions Fall risk precautions Referral to substance use disorder clinical specialist or psychiatry Caring and the "Art" of Nursing What is the patient likely experiencing/feeling right now in this situation? What can you do to engage yourself with this patient's experience, and show that he/she matters to you as a person? (Psychosocial Integrity) Education Priorities/Discharge Planning What educational/discharge priorities will be needed to develop a teaching plan for this patient and/or family? (Health Promotion and Maintenance) 2. What Patient is Experiencing: a. How to Engage: 3. Education PRIORITY: a. PRIORITY Topics to Teach: b. Rationale: Health Science Science Nursing Share QuestionEmailCopy link Comments (0)