It is now 7:45 am. You have received reports for each of your three patients on the med-surg unit. Question
Answered step-by-step
Asked by snadarajah14
It is now 7:45 am. You have received reports for each of your three patients on the med-surg unit of Anytown General Hospital, reviewed their charts, and are ready to begin your day. You have elected to assess them in the following order based on the information you were given from the overnight nurses: 1) Herbie Saunders 2) Gladys Parker 3) David Mueller
Initial Assessment Patient #1: Herbie Saunders
T: 98.4 F (oral)
P: 110 R: 24
BP: 132/78 (MAP 96 mmHg)
O2 sat: 91% on room air Pain:
denies Daily Weight: 198.4 lb (90.2 kg)
Fingerstick: 147
Focused Patient Assessment
As you enter the room, Mr. Saunders is sitting in the recliner breathing heavily. He states, with some difficulty, “I can’t….believe…..how winded….I am right now. I just….had….to go….to the bathroom.” Respirations are 28 and his continuous oxygen monitor reads 87%. He is on room air. Mr. Saunders’ oxygen saturation increases to 91% on 2 lpm oxygen via nasal cannula. Now that he has been resting for a bit, his respiratory rate has decreased to 22 and he is able to speak in full sentences. You listen to his lungs and hear crackles bilaterally in the bases. Mr. Saunders tells you that he tried to lay down earlier but that it was too hard to breathe so he had to sit up instead. You notice 3+ pitting edema to both ankles and Mr. Saunders tells you that this is much worse than it normally is at home. Pulses are present and palpable. Heart sounds are normal. Capillary refill < 3 seconds. You see that his 0530 lab results are now available in the patient's chart. Basic Metabolic Panel (BMP) + Mg - Yesterday @ 1730 Na K Cl CO2 BUN Creat. Gluc Mg 141 3.6 103 26 16 1.1 132 2.0 Initial Assessment Patient #3: Gladys Parker T: 96.9 F (oral) P: 95 R: 16 BP: 98/65 (MAP 76 mmHg) O2 sat: 96% on room air Pain: denies Focused Patient Assessment: Ms. Parker is sleeping, but she wakes up when you open the door all the way. She correctly states that she is in the hospital when you assess her orientation. She is unable to correctly state the year and tells you that Ronald Reagan is the president. She is unable to tell you why she is in the hospital and she cannot recall that she fell at her nursing home yesterday. Her pupils are round, equal, and reactive to light. Her grip strength is 5/5 in both hands, her lower extremity strength is 4/5 bilaterally. She denies numbness or tingling in her extremities. She denies dizziness. Her speech is clear and her face appears symmetrical. There is a bag of Lactated Ringer's infusing at 100 ml/hr and the bag is a little over half empty. Her IV dressing is clean/dry/intact. No redness or swelling at the site. Ms. Parker's call light is in bed next to her and the bed is in the lowest position. You notice that the bed alarm has been activated. When you ask her if she needs anything right away, Ms. Parker states, "I'm doing just fine except I sure would like some breakfast." Initial Assessment Patient #2: David Mueller T: 99.9 F (oral ) P: 101 R: 18 BP: 101/81 (MAP 88 mmHg) O2 sat: 93% on room air Pain: 5/10 Fingerstick: 287 Mr. Mueller is awake and up in the recliner when you enter the room. He tells you that his surgical site hurts more today than it did yesterday and he wants to know when he can have his next pain medication. He rates his pain at 5/10. You can see some strikethrough serosanguinous drainage on the stump bandage but it is not saturated to the point that it requires changing. Patient states, "The surgeon was here about an hour ago and he changed the dressing." You ask Mr. Mueller about his last bowel movement and he says that his last bowel movement was the day before surgery. It is now POD #2. He states he is passing gas and bowel sounds are present and active in all four quadrants. He denies abdominal pain, but states, "I'm a little uncomfortable. I feel like I need to go, but I haven't been able to yet." ANSWER THE QUETION WHIT HAT (THINKER) AND BLACK HAT CAN YOU HELP ANWER THE QUESTIONS CAREGORY WHITE HAT AND BLACK HAT WHIT HAT (THINKER) WHAT TO THINK ABOUT INFORMATION FACTS CHARTS AND GRAPHS DATA QUETION TO ASK WHATRE THE FACTS? WHAT INFO DO WE HAVE? wAHT ADDITIONAL INFO DO WE NEED? BLACK HAT WHAT TO THINK ABOUT RISKS OBSTACLES DOWNSIDES WEAKNESSE QUETION TO ASK WHAT COULD GO WRONG WILL THIS WORK? IS IT SAFE SCIENCE HEALTH SCIENCE NURSING NURS 401
It is now 7:45 am. You have received reports for each of your three patients on the med-surg unit
