History of Current Problem:
Jack Holmes a 72-year-old Caucasian male brought to the ED by ambulance from a skilled nursing facility (SNF). According to report from the paramedic, when the SNF nursing staff attempted to
...
History of Current Problem:
Jack Holmes a 72-year-old Caucasian male brought to the ED by ambulance from a skilled nursing facility (SNF). According to report from the paramedic, when the SNF nursing staff attempted to wake him this morning, he would not respond, and his BP was 74/40 with a MAP of 51. He has a history of Parkinson’s disease, COPD, CHF, HTN, depression, and a stage IV decubitus ulcer on his coccyx that developed three months ago. He does not follow commands, is unresponsive to verbal stimuli, but responds to a sternal rub with grimacing and withdrawing from stimulus.
Personal/Social History:
He has lived in the skilled nursing facility the past three years and has been bed bound the past year due to his advanced Parkinson’s disease. He was a heavy smoker, 1 PPD for 40 years until he moved to the SNF.
1. What is the RELATIONSHIP between RELEVANT current problem data and the primary medical problem?
2. What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?
3. What Jack’s Glasgow Coma Scale score?
4. What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse?
5. Interpret the rhythm
6. What diagnostic results are RELEVANT and must be recognized as clinically significant to the nurse?
Radiology Report: Chest x-ray
7. Address the results of the CBC- address each lab result
8. Address the results of the BMP –address each result
9. Address the results of the liver panel
10. Address the results of the UA
11. Lactate 7.4 Normal value 0.5-1 Critical value >2 Clinical significance
Based on your understanding of Lactate as it relates to shock identify 2 Nursing priorities and 2 interventions.
Deficient Fluid Volume- Increase fluid and electrolyte accumulation within the body to prevent cellular edema and cell death and promote oxygenation
What is the PROBLEM
12. Present the Pathophysiology of the problem and address -SIRS or MODS (does he have them or not and what supports that determination
13. Looking at your orders for Jack – what is the purpose or rationale for each one?
14. Identify 3 Nursing Priorities (first part of nursing diagnosis- These should be active problems)
. What will you do to address Jack’s psychosocial / emotional needs
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