Client Scenario 1 60-year-old female with a history of hypertension, Diabetes Type ll and smoking. . Question
Asked by busola
Client Scenario 1
60-year-old female with a history of hypertension, Diabetes Type ll and smoking.
The patient complains while getting registered in the ER of indigestion unrelieved with antacids, nausea, fatigue, and her skin is cool and clammy.
The patient was brought to the triage bay, and this is the patient’s rhythm on the bedside telemetry monitor:
Client data:
BP is 180/100
HR 60
RR 24
Pulse ox: 91%
Chest pain -5/10
Assessment
From Slide 2 and 3: List the signs and symptoms and mark each as being normal or abnormal. Also list any items that would be identified as relevant history.
Signs and symptoms Normal vs. abnormal Identify history of
Nursing Diagnosis:
Determine client needs by analyzing your assessment findings and:
Identify 3 relevant nursing diagnoses
Identify one issue that may create confusion for this scenario.
Which of the 3 Nursing diagnoses is the priority?
Why?
Planning
Identify nursing actions on next three slides to address the nursing diagnosis: complete the chart with the top interventions and those to avoid. Nursing Diagnosis #1
Nursing Actions Nursing Actions to avoid
Nursing Diagnosis #2
Nursing Actions Nursing Actions to avoid
Nursing Diagnosis #3
Nursing Actions Nursing Actions to avoid
Prioritizing Orders: Prioritize the medical orders.
Medicate with S.L. nitroglycerin (unless patient is hypotensive
Draw cardiac troponins
Call RRT if not in the ED
Start an IV site
Apply oxygen per nasal cannula
Check patient’s HR, RR, B/P
Get a 12-lead EKG done STAT (call for someone to bring the EKG machine to the bedside, don’t leave the patient).
Notify healthcare provider of situation
Follow any other healthcare provider’s orders
Interventions:
Place your actions in priority order and provide rationale on next two slides.
Priority orders Rationale
Evaluation
Complete the chart by indicating that plan of care was effective, ineffective or unrelated after your priority care?
Assessment Finding Effective Ineffective Unrelated
Chest pain- 2/10
EKG -resolution of ST elevation
BP- 180/100
Heart rate 65
Pulse OX : 95%
Skin temperature- dry and warm
SCIENCE
HEALTH SCIENCE
NURSING
COMPLEX CR NR 341
Client Scenario 1 60-year-old female with a history of hypertension, Diabetes Type ll and smoking.
