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PRIORITY Patient Activity

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Part I-Patient Care Scenarios You are the RN on a busy medical-surgical/telemetry floor at Anytown General Hospital. Each nurse on your unit typically cares for 3-5 patients. You have just arriv... ed for your day shift and are receiving nurse-to-nurse reports from three different night shift nurses. After you receive reports, you will have an opportunity to review the current orders for each of your patients. NOC Nurse Report Patient #1: Herbie Saunders Patient Report: What Do You Notice? Clinical Significance: “Herbie Saunders is a 62-year-old male who came in last night for a CHF exacerbation. His doctor is Dr. Davis and he’s a full code. He’s alert and oriented and can make his needs known. He’s on tele, normal sinus rhythm with occasional PVCs. His pressures are fine, heart rate is in the 70s. Lungs are clear in the uppers with crackles in the bases. He’s coughing up a small amount of white frothy secretions. He’s been on room air since he arrived, oxygen sats are in the low-mid 90s. He got 40 mg IV Lasix last night in the ED; I think you might have something scheduled during your shift but I haven’t given anything overnight. He has a 20 gauge in his right forearm. I’m not sure how he gets around since he’s been in bed since he got here.” The patient has occasional PVC, white frothy secretions, abnormal lung sounds and had a CHF exacerbation. He is receiving 40 mg of IV Lasix and has a 20 gauge IV in right forearm. Also, the nurse does not know how the patient gets around since he’s been in bed since admission. Patient has CHF which can in turn cause pulmonary edema which is displayed by the crackles in his lungs and white frothy secretions. Which may be worsened by not ambulating. Patient is receiving IV Lasix due to his accumulation of fluids, the diuretic given will allow the patient to secrete this fluid. Most Recent Vital Signs @ 0357 What Do You Notice? Clinical Significance: T: 98.6 F (oral) P: 76 R: 20 BP: 128/87 (MAP 101 mmHg) O2 sat: 92% on room air Pain: denies Admission Weight: 196 lb (89.1 kg) Vitals of the patient are normal Overall, well maintained vitals and no signs of distress. [Show More]

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