Mobility VCBC Post Work (Nusrsing)
Posted by:admin | June 4, 2021
This is a Unfolding Case Study
Patient Details:
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Case Study History
Name:
James, Karen
Age:
57 Years
Gender:
Female
Karen James is a 57-year-old female who was admitted to the medical-surgical unit from her primary care physician’s office for treatment and evaluation of persistent and worsening influenza. She has a past medical history of asthma as well as depression and anxiety.
You are currently working on Phase 1. You have completed Phase 0 of this scenario.
Patient Details:
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Case Study History
Name:
James, Karen
Age:
57 Years
Gender:
Female
Phase
1,
Wednesday
16:00
You have assumed care for Ms. James who is admitted to the medical-surgical unit for rehydration and management of respiratory distress.
Orient yourself to the patient and health record by locating the following pieces of information within the System Assessment Report and Patient Teaching, and type your answers in a Miscellaneous Nursing Note:
1). Run a report on all the System Assessments documented for the patient in the last 24 hours. You will need to go to Patient Charting System Assessments Show Saved Charting. What was documented for the respiratory effort? What was auscultated in the Lower Right Posterior lobe of the lungs? What was documented related to tissue perfusion?
2). What was the last documented temperature for Karen?
3). Does Ms. James use any sensory aides?
4) What does she rate her pain?
5) What is her MORSE Fall Risk Score?
Review the client’s History and Physical, what indications can you see place this patient at risk for mobility issues or falls?
[LEARNER ACTION: In a misc nursing note identify risks for mobility and falls. Explain her score on the MORSE scale.]
When you are finished with this task, you may click Complete this Phase.
Patient Information
Chief Informant:
Patient
Chief Complaint:
Shortness of breath, productive cough
History of Current Problem:
Patient states she has had 3-week history of influenza. Has now developed a severe cough approximately 3 days ago with shortness of breath. Unable to sleep due to cough, which often causes bronchospasms. Patient also complains of fever, fatigue, and right-sided chest pain. Seen in urgent care 3 days ago and given Z-pack. No improvement in symptoms.
Allergies:
None known
Family History:
Mother died at age of 72 with breast cancer. Father is alive at the age of 79 and has congestive heart failure.
Past Medical History
Previous Illnesses:
Patient has asthma. Also states she gets bronchitis every 1-2 years.
Contagious Diseases:
None
Injuries or Trauma:
None
Surgical History:
Tonsillectomy and adenoidectomy as a child.
Dietary History:
Regular diet. Patient is 5’1″ and 140 pounds. Has recently lost 20 pounds on Weight Watchers diet.
Other:
—
Social History:
No smoking, no drugs. Uses alcohol in social situations.
Current Medications:
Tylenol 650 mg PO every 4 hours PRN pain or fever
Prozac 20 mg PO every day
Xanax 0.25 mg PO every 8 hours PRN
Xopenex HFA 2 puffs every 6 hours PRN
Review of Systems
Integument:
Denies complaints.
HEENT:
States she had neck soreness related to influenza, with “swollen glands.”
Cardiovascular:
No complaints.
Respiratory:
Complains of shortness of breath, frequent productive cough. States her cough often turns into bronchospasms. Uses inhaler, peppermint tea, lozenges, and Vicks VapoRub.
Gastrointestinal:
Complains of decreased appetite.
Genitourinary:
No complaints.
Musculoskeletal:
Complains of generalized body aches.
Neurologic:
Alert and oriented.
Developmental:
Denies complaints.
Endocrine:
No complaints.
Genitalia:
No complaints.
Lymphatic:
No complaints.
Physical Exam
General:
57-year-old female in mild distress. Appears weak.
Vital Signs:
Temp: 103.2 F, Pulse: 114, Resp: 28, Blood pressure: 154/78 in office this morning
Integument:
Skin clear of rash.
HEENT:
Pupils equal and reactive. Nasal congestion. Neck supple.
Cardiovascular:
S1, S2, no murmur.
Respiratory:
Lungs clear with crepitation in right base.
Gastrointestinal:
Abdomen soft, active bowel sounds.
Genitourinary:
—
Musculoskeletal:
Moves all extremities well.
Neurologic:
Alert and oriented.
Developmental:
—
Endocrine:
—
Genitalia:
Not assessed. Seen by gynecologist recently. Negative pap smear and negative mammogram.
Lymphatic:
No lymph node swelling at this time.
Impressions:
Pneumonia
Plan:
The patient is admitted for IV antibiotics and close observation of respiratory status. Patient will need influenza and pneumonia vaccines.
Provider Signature:
Michael Foster, MD
Day:
Wednesday
Time:
12:45
Chief Complaint:
The patient is a 57-year-old female admitted today for chief complaint of shortness of breath.
Patient’s labs were completed in the primary care provider’s office prior to admission and results include the following:
WBC: 20.2 x 109/L
RBC: 4.51 RBC x 106/ul
Hemoglobin: 14.0 g/dL
Hematocrit: 40.2%
Sodium: 139 mEq/L
Potassium: 4.2 mEq/L
Chloride: 105 mEq/L
CO2: 26 mEq/L
Glucose: 91 mg/dL
BUN: 17 mg/dL
Creatinine: 0.5 mg/dL
She is also febrile at 102.7.
Nursing will initiate IV antibiotics.
Showing 1 to 1 of 1 entries
FirstPrevious1NextLast
Chart Time
Temp
Resp
Pulse
BP
Sat%
Notes
Entry By
Wed 12:45
102.7
22
112
142/77
98
C Diaz, RN
Select Chart Type: Temperature Respiration Pulse Blood Pressure Oxygen Saturation
Select and drag to zoom in on a date range
102.7F/39.3C
Patient Card
Order Day/Time
Description
Category
Last Performed
Discontinue
Wed | 13:00
Admit to medical-surgical
Alerts
—
Wed | 13:00
Start and maintain IV line
IV
—
Wed | 13:00
Pulse oximetry every 4 hour(s)
Respiratory
—
Wed | 13:00
Vital signs every 4 hours
Vital Signs
—
Wed | 13:00
Up as tolerated
Activity/Mobility
—
Wed | 14:00
Diagnosis-Respiratory distress syndrome-ADDED-Disease Process
Patient Teaching
—
Wed | 13:00
Regular/General Diet
Diet
—
Showing 1 to 7 of 7 entries
FirstPrevious1NextLast
PRN
Drug Name
Order Start
Order Stop
Dose
Route
Frequency
Dosage Time
Action
Acetaminophen Tablet – (Tylenol, Genapap)
Wed 13:00
Tue 23:59
650 mg
Oral
Every 6 Hours PRN
– –
Levalbuterol Nebulizer Solution – (Xopenex Nebulizer Solution)
Chart:
System Assessments Wed 13:00
Entry Time:
Wed 13:00
Entered By:
C Diaz, RN
Cardiovascular Assessment
Pulses
Apical:
Regular
Tissue Perfusion
Peripheral vascular, general:
Warm extremities
Edema
No edema noted
Cardiac Assessment
No cardiac problems noted
Respiratory Assessment
Productive Cough Secretions Assessment
Color:
Green
Amount:
Scant
Cough
Cough strength:
Strong
Cough type:
Productive
Oxygenation
Respiratory/breathing support:
Nebulizer treatment
Lower Right Posterior
Auscultation:
Coarse crackles
Lower Left Posterior
Auscultation:
Diminished
Upper Right Posterior
Wheeze Description:
Expiratory
Auscultation:
Wheeze
Upper Left Posterior
Wheeze Description:
Expiratory
Auscultation:
Wheeze
Productive Cough Secretions Assessment
Consistency:
Thick
Secretion odor:
None
Upper Left Anterior
Auscultation:
Clear
Upper Right Anterior
Auscultation:
Clear
Respiratory Effort
Dyspnea/shortness of breath
Shortness of breath on exertion
Respiratory Pattern
Labored
Neurological Assessment
Level of Consciousness/Orientation
Oriented to person, place, time, and situation
Emotional State
Calm
Cooperative
Central Nervous System Assessment (CNS)
No CNS problems evident
Integumentary Assessment
Integumentary Assessment
No assessment required at this time
Sensory Assessment
Vision Assessment
Wears glasses
Wears contacts
Musculoskeletal Assessment
Range of Motion (ROM)
Moves all extremities with full range of motion
Gastrointestinal Assessment
Abdomen
Abdominal assessment:
Soft to palpation
Gastrointestinal
No gastric problems noted
Intestinal
Date of last bowel movement:
Monday
Continence of bowel:
Continent
Intestinal assessment:
No bowel problems noted
Bowel sounds:
Active x 4 quadrants
Rectum:
No reported rectal problems
Pain Assessment
Do You Have Pain Now?
No
Genitourinary Assessment
Genitourinary Assessment
No assessment required at this time
Psychosocial Assessment
Psychosocial Assessment
No assessment required at this time
Safety Assessment
Orientation
Oriented to time, person, place
Fall Risk
30
Bracelet Check
Hospital ID bracelet
Safety Notes
Low fall risk
Morse Fall Scale
History of Falling
No=0
Secondary Diagnosis
No=0
Ambulatory Aid
None/Bedrest/Nurse Assist=0
IV or IV Access
Yes=20
Gait
Weak=10
Mental Status
Oriented to Own Ability=0
Total Fall Risk Score
Risk Score:
30
Fall Risk Score and Preventative Measures Implemented
Fall Risk Level:
Medium Risk
Fall Risk Measures:
Implement
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