- Please Help Me Answer The Questions Below Thank You So Much 1 Abnormal Assessment Findings Recognize Cues Assessment 1 (125.62 KiB) Viewed 15 times
Assessment: What are theidentified abnormal findings:
2.
Analysis/Hypothesis: What is thecause of the patients problem that must be prioritized at thistime?
3. Planning (Patientgoals focus on resolving the problem), Mustbe SMART goals GenerateSolutions
Develops a list of actions to address the priorityhypothesis. The student nurse then selects the appropriate actionfrom the list and carries out the action.
4. Implementation (Specificnursing interventions that were performedduring your shift): Take Action
Sorts the hypotheses (probable client needs, concerns, problems)in order (based on their evaluation in various dimensions) andcarries out the action(s) to address the hypothesis/hypotheses withhighest priority.
Must contain thefollowing: Assess {observe, auscultate,palpate, percuss}; Monitor; Prepare, administer;Collaborate w/ specific multi-disciplinary team;& teach, i.e., VERBS
5. Evaluation (Whatwas the outcome: Did you meet your desiredgoal?) TIMEOUT!! Re-Assess the Patient: Doyour interventions address further monitoring of the patient’sresponse to your interventions and to the achievement of thedesired outcome? Are qualifiers: when, how, amount, time, andfrequency used? Is the focus of the action’s verb on the nurse
Goal; Met or Not met or partially met and how torevise.)
Goal: □Met Goal: □ NotMet Goal: □ PartiallyMet Goal: □ Unable to Assess
Case Study #4 Romina Jackobs is a 45-year-old morbidly obese French woman who moved to the al US one year ago for a job promotion. She lives alone with her two cats. She says that she has made a lot of friends in the apartment building that she lives in, and her neighbor has called her and let her know that she will take care of her cats. Because she has only been in her new position for a year, she is worried that she will get into trouble if she has to miss too many days. As a regional public relations manager for Delta airlines, she has to travel a lot, she is worried she will miss a lot of her reports. She presented in the ER this morning complaining about pain in her right calf. On assessment her calf was red, edematous and hot to the touch. There was a palpable mass in the calf, so Romina was sent to ultra sound. Ultra sound revealed that there was an encapsulated mass in the calf, and pt was sent to CT scan. CT revealed that there was a large abscess in Romina's calf. The admitting doctor has put in orders for admission with a diagnosis of Abscess, a consult for surgery, wound care nurse evaluation post surgery, home health care consult on discharge, social worker consult, wound culture. The doctor has also ordered a transesophogeal Echocardiogram. Lab values were: WBC 17,000 RBC 4.5 Hbg 13 HCT 35 Vital signs were: HR 115 BP 165/98 01 8 mat RR 24 Temp 102.3 02 98 Reismo n JACKOR MElo
Case Study #4 Romina Jackobs is a 45-year-old morbidly obese French woman who moved to the US one year ago for a job promotion. She lives alone with her two cats. She says that she has made a lot of friends in the apartment building that she lives in, and her neighbor has called her and let her know that she will take care of her cats. Because she has only been in her new position for a year, she is worried that she will get into trouble if she has to miss too many days. As a regional public relations manager for Delta airlines, she has to travel a lot, she is worried she will miss a lot of her reports. She presented in the ER this morning complaining about pain in her right calf. On assessment her calf was red, edematous and hot to the touch. There was a palpable mass in the calf, so Romina was sent to ultra sound. Ultra sound revealed that there was an encapsulated mass in the calf, and pt was sent to CT scan. CT revealed that there was a large abscess in Romina's calf. The admitting doctor has put in orders for admission with a diagnosis of Abscess, a consult for surgery, wound care nurse evaluation post surgery, home health care consult on discharge, social worker consult, wound culture. The doctor has also ordered a transesophogeal Echocardiogram. Lab values were: WBC 17, 000 RBC 4.5 Hbg 13 HCT 35 Vital signs were: HR 115 BP 165/98 RR 24 Temp 102.3 02 98 map 22 2016