Question

Evaluation: Three hours after admission…

All orders have been implemented and consults have been called.

Ben’s mother arrives at the hospital. Pamela is slurring her speech, and her eyes appear glazed. Pamela admits to the nurse that she stopped and had a single glass of wine prior to coming to the hospital. Ben becomes agitated and inconsolable when his mother attempts to pick him up. The nurse calls hospital security and a cab is called for Pamela.

Current VS:	Most Recent VS:	Pain Assessment – FLACC scale (0-2 points)
T: 97.2°F (36.2 C)	T: 96.8°F (36.0 C)	Face:	0
P: 141	P: 150	Legs:	0
R: 32	R: 34	Activity:	0
BP: 82/40	BP: 75/50	Cry:	0
O2 sat: 98% on room air	O2 sat: 97% room air	Consolability:	2

Current Assessment:
GENERAL APPEARANCE:	Ben is awake and alert, respirations regular and unlabored.
RESP:	No respiratory distress noted. Lungs clear throughout.
CARDIAC:	Apical pulse regular, no murmurs or abnormal sounds noted.
NEURO:	Pupils round, reactive. Volunteer present in Ben’s room, holding him in a rocker. Resting calmly.
GI:	Bowel sounds audible x4. Last BM still unknown.
GU:	Voiding without difficulty
SKIN:	No open wounds or skin concerns noted.

1. What clinical data is RELEVANT that must be recognized as clinically significant?

RELEVANT VS Data:	Clinical Significance:
RELEVANT Assessment Data:	Clinical Significance:

2. Has the status improved or not as expected to this point?

3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?

4. Based on your current evaluation, what are your nursing priorities and plan of care?

.

It is now the end of your shift. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact Ben’s care. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will be caring for this patient:

Situation:

Name/age: BRIEF summary of primary problem:

Background:

Primary problem/diagnosis: RELEVANT past medical history: RELEVANT background data:

Assessment:

Most recent vital signs: RELEVANT body system nursing assessment data: RELEVANT lab values: INTERPRETATION of current clinical status (stable/unstable/worsening):

Recommendation:

Suggestions to advance plan of care:

Education Priorities/Discharge Planning

1. What will be the most important discharge/education priorities you will reinforce with their medical condition to prevent future readmission with the same problem?

2. What are some practical ways you as the nurse can assess the effectiveness of your teaching?

Caring and the “Art” of Nursing

1. What is the patient likely experiencing/feeling right now in this situation?

2. What can you do to engage yourself with this patient’s experience, and show that he matters to you as a person?

Use Reflection to THINK Like a Nurse

Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment.

1. What did I learn from this scenario?

2. How can I use what has been learned from this scenario to improve patient care in the future?

Answer 1

Relevent Vital sign data :

• low temperature :Low body temperature usually happens from being out in cold weather. But it may also be caused by alcohol or drug use, going into shock , or certain disorders such as diabetes or low thyroid . A low body temperature may occur with an infection. This is most common in newborns, older adults, or people who are frail.
• low blood pressure: This means the heart, brain, and other parts of the body do not get enough blood.
• High breathing rate:Rapid breathing can be the result of anything from anxiety or asthma, to a lung infection or heart failure.
• High pulse:A high heart rate can also mean the heart muscle is weakened by a virus or some other problem that forces it to beat more often to pump enough blood to the rest of the body. Usually, though, a high heart beat is not due to heart disease, because a wide variety of noncardiac factors can speed the heart rate.

Except his BP improving a little bit , everything else isnt.

Since the changes is the vital signs arent so drastic i dont thing theres a need to change plan of care

Some of the top nursing priorities would be :

• pursed-lip breathing.
• abdominal breathing.
• performing relaxation techniques.
• performing relaxation techniques.
• taking prescribed medications (ensuring accuracy of dose and frequency and monitoring adverse effects)
• scheduling activities to avoid fatigue and provide for rest periods.