Question

Handoff report at 0800

“The patient is a young man who was transferred from the ICU yesterday. He was in a motor vehicle accident (MVA) 14 days ago. He had some head trauma and subsequent evacuation of a subdural hematoma. He is unconscious, unresponsive to painful stimuli, and has flaccid extremities. Pupils round, sluggish reaction to light. He has several abrasions on his face and several bruised areas on his shoulders and chest from the accident. Vital signs are T: 97.8, P: 94, R:24, BP: 124/80, pulse ox 94%. Mother at bedside; she questions everything you do.”

The patient’s current flowcharts contain the following information:

Nursing Care Plan	Medical History
Oral suction prn Diet: NPO VS & Neuro checks q4h O2 @ 3L/NC Foley Seizure precautions I&O HOB 30o at all times LBM ______ Peg tube clamped IV: TPN at 80mL/via right subclavian Central line triple lumen Fingerstick BG q6h 1200-1800-2400-0600 Routine Medication: Dexamethasone 4 mg IVP q6h 1000-1600-2200-0400 Prn Medication: Dulcolax Supp 1 prn no BM	18-year-old high school student involved in a MVA in which he was the driver. Passenger in the care died from injuries. Pt. unconscious on arrival to the ER. Drug use: Family not aware of any use. Blood alcohol level on admission 0.16%. Family wants to continue all possible treatment. Not willing to discuss code status at this time.

1) Review the data in the flow charts and identify the information that needs follow-up :

2) It is 0830; When the handoff report is completed. Prioritize your plan of care for the next 3 hours

TIME. Plan of Nursing Care

0830

0930

1030

2:00 PM nursing assessment: Pupils round to R & L, nonreactive to light. R:12 Cheyne-Stokes, P 80, BP 150/80. Skin warm, jerky movements of upper extremity noted. The physician writes the following orders:

• Oxygen at 12L/min per non-rebreather mask
• Check oxygen saturation q1h
• Vital signs q1h
• CT scan of the head stat
• ABGs stat

1) Identify the nursing interventions that require immediate follow-up:

2) Identify the nursing actions that you can delegate/assign to unlicensed assistive personnel

3) Critical Reflection: To provide patient-centered care, list how you would support the mother at this time?

Answer 1

1, followup needed for
Vital signs, neuro assessment, intake and output chart monitoring, oxygen check, seizure precautions, and bed end elevation at 30 degrees, TPN monitoring, medication administration, and fingerstick glucose monitoring.
2, 8.30 - vital signs and neuro assessment, I&O chart, oxygen administration, and seizure precautions
9.30-oral suction, seizure reaction, I&O chart, oxygen administration, head of the bed elevated 30degree
10.00 medication administration, dexamethasone 4mg IVP, TPN check
1, Immediate assessment:
-administer o2 at 12lit/min from a nasal catheter to a non-rebreather mask.
-check the patient breathing pattern.
-check o2 sat and vital signs
-transfer the patient immediately to CT scan
-check ABG and inform to doctor
-maintain seizure precaution
-continue neuro assessment.
-make record-keeping
2, Unlicensed assistive personal can help RN inpatient care activity, can make an observation on patient breathing, adverse effects, and other potential harm. can transfer the patient to investigation and other procedures, can check patient vital signs, and perform personal hygiene for patients.
3, collaboration and relationship with mother can focus on patient priority, preference, and values. include the mother in daily care activity and decision making that improve patient care, increase trust, safety, and quality and learning ability, and improve knowledge and skills of mothers that help them in-home care. listen to the mother's concern and choice and respect their beliefs and cultural background in the plan of care. Share the information with the mother timely, accurately to participate in care effectively. these are the core concepts for patient-centered care when we include family in patient care.