Assignment
K.N is a 35-year-old female admitted to the hospital today with severe abdominal pain, liquid stools 7 to 10 times daily, and blood in her stool. She has an 8-year history of Crohn's disease. S.L.'s symptoms have worsened over the last week. She had taken prednisone for several months and was weaned off of the medication a couple of months ago.
• Admission Order: CBC; BMP; Fe; pre-albumin; stool culture; guaiac stools; I&O including number and character of stools; daily weights; up with assistance; NPO, bowel rest; IV D 5W, infuse at 80 mL/hr; IV methylprednisolone 80 mg in 50 mL D5W q 6 hr., infuse over 15 minutes; blood glucose finger stick q 8 hr., acetaminophen 500 mg, two tablets q 6 hr. PO PRN for pain. Full code.
• Labs and Diagnostics: The abdominal CT shows small bowel wall thickening in the terminal ileum, with affected bowel loops separated by fibrofatty proliferation. Na 131, K 3.3, Cl 95, CO2 30, BUN 8, Creat 2.58, Ca 10.2, Fe 8.9, pre-albumin 12, glucose random 125, WBC 13.6, H&H 6.7/17.9 Guaiac-positive
• Day of Care Assessment: 1400 VS: T 38.2° C (100.8° F), BP 106/68, P 94 and regular, R 24 and unlabored.0 2 saturation 94% on RA. Pain 7/10 in right lower abdominal quadrant that is intermittent. A&Ox4, PERRLA. Lungs clear. Apical pulse is 94 and regular. BS hyperactive in all quadrants. Abdomen is firm, distended, and tender over the right lower quadrant, no masses palpable. Skin warm, pale, and dry. Capillary refill
Task
A. Medical Management - Briefly Explain the medical condition or injury and expected management. Demonstrate that you are connecting the dots between the patient's risk factors for the issue, how you would explain the issue to the patient (don't overwhelm the patient - keep it simple but clearly correct with the most important parts included), why the tests and which additional tests might be made, analysis of the test results - expected versus unexpected, what the category of drug or drugs is why it is or they are ordered, and what the expected patient response will be (why are they taking it) ?
B. Sufficient Data - Identify the significant day of care assessment data pertinent to the reason for hospitalization that supports prioritization of the patient?
C. Priority Rationale - What is the rationale for prioritization of the patient?
D. Priority Problem - What do you see is the priority problem (nursing diagnosis) for the priority patient? This should be a 3 part diagnosis as an At Risk For diagnosis would not indicate a priority issue. The problem should be directly related to the reason they are the priority patient?
E. Goal and Activities - What is the most important thing your patient wants to achieve today - Identify interventions with evidence based rationales?
F. Collaboration - Discuss your understanding of collaboration in describing who you would want to collaborate with and what you would be asking for from that discipline?
G. Delegation - Discuss your understanding of delegation in describing how you would best utilize an LPN and a CNA to provide patient centered care?
H. Legal/Ethical - Connect theory class content - Legal principles or ethical principles to the issue you identify?
I. Staff Education on Safety (or other important issue) - Make sure the focus is on staff education not patient education. Discuss basic principles of teaching and explain not only the topic you would teach but how you would teach the topic?