solved

solved. Question
Answered step-by-step
Asked by Ofurepalace

Having received report, you enter Mrs. Willis’ room, wash your hands, introduce yourself, measure vital signs and height and weight, and complete initial assessment.

…Vital Signs…

Temperature: 99.5 degrees Fahrenheit (37.4 degrees Celsius), tympanic…

Heart rate: 84, radial…

Respirations: 22…

Blood pressure: 138/74 mmHg, left arm, lying…

Oxygen saturation: 94% on 2 L/min via nasal cannula, finger probe…

Height: 5 ft, 1 in…

Weight: 96 lbs, standing scale…

Mrs. Willis is alert, oriented, calm, and cooperative at this time. Her overall appearance is neat and clean, but she smells heavily of cigarette smoke. She reports an aching, constant chest pain that she rates as 4 out of 10, triggered by coughing and relieved by rest and relaxation. She guards her chest and winces when she moves.

Pupils are equal, 4 mm, round, and briskly reactive to light and accommodation, with normal sclera and conjunctiva. Hand grip is equally strong bilaterally. Mrs. Willis’ cranial nerves II-XII are normal, and motor and sensory examinations reveal normal findings. Reflexes are present and symmetrical in all extremities.

Mrs. Willis reports that her vision is “fine” with glasses during the day. She reports difficulty seeing at night. She reports no hearing problems, and she is able to hear you whisper.

Mrs. Willis has full range of motion in all extremities but appears unsteady and weak. Gait is unsteady and balance is unsure.

Gums and mouth are in good condition with no sores or lesions. Teeth show aging dental work and are in fair condition. Mrs. Willis reports no swallowing problems and demonstrates swallowing with no difficulty.

Abdomen is flat, soft, and nontender to palpation. Mrs. Willis reports no gastrointestinal or urinary problems. Mrs. Willis reports that she is continent of urination and bowel movements. Last bowel movement was yesterday; she reports more frequent constipation because she “does not eat right.” There are bowel sounds in all quadrants, but they are infrequent and low pitched.

Mrs. Willis’ skin is pale, cool, moist, and intact. You note slight tenting. Her hair distribution and characteristics are thin but healthy appearing. Her scalp is normal. Nails are smooth, intact, pink, and well groomed. Slight clubbing is noted.

Apical pulse is regular. No murmurs are noted. Carotid pulse assessment reveals regular rhythm with no murmurs. Brachial, radial, popliteal, and dorsalis pedis pulses are bilaterally equal and regular. All pulses are palpable as expected. Capillary refill is less than 3 seconds in all extremities. Mucous membranes are pink and moist. No cyanosis or dependent edema is present in the extremities. Cardiac assessment reveals S1, S2 regular rate and rhythm with no murmurs or abnormalities.

Lung sounds are diminished bilaterally in middle and lower lung sound fields with slight expiratory wheezing bilaterally in upper lung sound fields, and she has a productive cough with thick foul-smelling, green-yellow sputum noted on tissues. She complains of slight heaviness with breathing, “like breathing underwater.”

Mrs. Willis states, “I am worn out all the time. I can’t even make it out of the house most days.”

[STUDENT ACTION: Document your assessment findings.]

While completing your assessment, Mrs. Willis reveals that she lives with her sister who is also a widower. Her cancer has depleted all of her finances, and she is no longer able to afford many of her medications or recommended treatments. Mrs. Willis reports that her pain is becoming worse by the day. She has not reported this to her doctor because she does not want any more expenses. When asked about her pain right now, she tells you that it is about 7 on a 10-point scale. She also shared that next week, social services had arranged for her to begin receiving home health care and a social worker to help her determine supportive services she may require. Today, she is simply focused on getting out of the hospital. Mrs. Willis also asks if she can be taken outside to have a cigarette, as it has been a while since she had one.

[CRITICAL THINKING: What nursing orders or consults would be appropriate to place for this patient?]

[STUDENT ACTION: Document appropriate assessments, orders, and consults in the EHR.]

Upon documenting your assessment and reviewing the EHR, you notice that there are no pain medications ordered.

You place a call to the provider, provide an SBAR report, and receive a new order.

[STUDENT ACTION: Document your SBAR communication with the patient’s provider. Review, verify, and enter the new order.]

When you have completed the above tasks, you may click Complete Phase.

 

 

    

    

 

SCIENCE
HEALTH SCIENCE
NURSING
NUR 303

solved