NSG 527-Initial Nursing Assessment DQ

ORDER NOW FOR AN ORIGINAL PAPER!!! NSG 527-Initial Nursing Assessment DQ .

History of Present Illness: Mary O’Reilly is a 55-year-old female with a prior history of partial colectomy w/colostomy who was admitted to the

medical/surgical unit for small bowel obstruction. Yesterday she developed severe RLQ abdominal pain and CT revealed

a perforated small bowel with free intraperitoneal air. Before she was brought to the operating room (OR) for an

exploratory laparotomy, her lactate was 4.9, WBC 18.9, and her systolic BP began to drop to 65-75, with a mean arterial

pressure (MAP) of 50-55. She received a total of 2500 mL of 0.9% NS preop and piperacillin-tazobactam 4.5 g. IVPB.

Her last BP before she went to the OR was 94/52 w/MAP 65.

What data is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential)

RELEVANT Data: Clinical Significance:

Present Problem: Mary had an exploratory laparotomy that required extensive lysis of adhesions and was found to have a perforated

jejunum with fecal peritonitis. Mary has a 7.0 mm endotracheal tube (ET) that is well secured, 23 cm at the lips. Current

vent settings are: CMV/AC rate 12, TV 500 mL, PEEP +5, FiO2 35%. She has an arterial line placed in the right radial

artery and a central line was placed in the right internal jugular (RIJ). Placement was confirmed by chest x-ray.

Mary

received 2.5 liters of LR during the case and had an estimated blood loss (EBL) of 375 mL. To maintain adequate

perfusion during surgery, she required norepinephrine IV gtt, currently at 10 mcg. Her SBP was consistently in the 90-

100s during surgery with a mean arterial pressure (MAP) of 65-70 and CVP: 12. She has a wound VAC applied to her

open abdominal incision with an intact dressing at 125 mm suction with no drainage and a 14 Fr. Salem Sump NG, 68 cm

in the left nare.

What data is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential)

RELEVANT Data: Clinical Significance:

Mary is coming to ICU after surgery and the OR

nurse provides you with the following report:

Patient Care Begins: Cardiac Telemetry Strip (6 seconds):

Regular/Irregular: P wave present? PR: QRS: QT:

Interpretation:

Clinical Significance:

Current VS: T: 99.4 F/37.4 C (oral)

P: 94 (regular)

R: 20 (AC: 12)

Arterial BP: 92/55 MAP: 67

O2 sat: 96% w/FiO2 35% ventilator

What VS data are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Health Promotion and Maintenance)

RELEVANT VS Data: Clinical Significance:

Current Head to Toe Nursing Assessment:

GENERAL SURVEY: Body relaxed, no grimacing, appears to be resting comfortably with no restlessness noted. Peripheral IV and central line well secured w/dressings intact, no redness or signs of

infection present, LIS suction w/NGT, ET 23 cm at lip, NGT 68 cm, tape secure on nasal Initial Nursing Assessment DQ

bridge and NG tube.

NEUROLOGICAL: PERRLA-3 mm, opens eyes briefly when name called, but then goes back to sleep, limited

spontaneous movements of all extremities noted

HEENT: Head normocephalic with symmetry of all facial features, sclera white bilaterally,

conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and moist. Biteblock for

ET properly placed.

RESPIRATORY: Breath sounds coarse bilat but clear after deep suctioning with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally. Vent settings confirmed: AC

rate 12, TV 500 mL, PEEP +5, FiO2 35%. Total RR 20, peak inspiratory pressures 16-20.

Actual TV: 500-600. Moderate amount of clear, creamy oral secretions requiring suctioning,

small amount of tan, thick secretions suctioned from ETT.

ORDER NOW FOR AN ORIGINAL PAPER!!! NSG 527-Initial Nursing Assessment DQ .

After receiving report from the nurse in PACU, the patient is brought

back to ICU and you collect the following assessment data:

CARDIAC: Pink, warm & dry, no edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2

noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted

at 30-45 degrees. Moderate generalized edema with 2+ pitting edema in lower extremities

ABDOMEN: Abdomen large, round, firm to touch. Midline open abdominal incision appx 6” (15 cm) in

length and 1.5” (4 cm) wide filled with intact transparent dressing. Wound V.A.C. at 125

mm suction-no drainage. BS absent in all 4 quadrants, colostomy bag intact with small

amount of dark brown stool in bag, stoma pink, with brisk refill <1 second with blanching of

stoma.

GU: Urinary catheter secured on thigh, 100 mL urine clear/yellow in drainage bag/urometer the

past hour

INTEGUMENTARY: Skin warm, dry, intact, normal color for ethnicity. No clubbing of nails, cap refill <3

seconds, Hair soft-distribution normal for age and gender. Skin integrity intact, skin turgor

elastic, no tenting present.

What assessment data is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Health Promotion & Maintenance)

RELEVANT Assessment Data: Clinical Significance:

Based on your nursing assessment, use the CPOT to rate the pain in an intubated patient. Is her pain

adequately controlled using the parameters of this tool?

Critical Care Pain Observation Tool (CPOT):

Intubated? Yes/no Yes

Facial Expression: Relaxed: 0/Tense: +1/Grimacing: +2 0

Body Movements: Absence: 0/Protection: +1/Restlessness: +2 0

Muscle Tension: Relaxed: 0/Tense/rigid: +1/Very tense/rigid: +2 0

Total Score: 0

Based on your nursing assessment, use the RASS to rate the sedation level. What level of sedation is

ordered? Is sedation adequate?

Richmond Agitation-Sedation Scale (RASS) Combative: +4 Overtly combative or violent, immediate danger to staff.

Very Agitated: +3 Pulls on or removes tubes or catheters or is aggressive.

Agitated: +2 Frequent non-purposeful movement or ventilator dyssynchrony. Initial Nursing Assessment DQ

Restless: +1 Restless, anxious or apprehensive but movements not aggressive or vigorous.

Alert and Calm: 0 Alert and calm.

Drowsy: -1 Drowsy, but sustains more than 10 seconds awake, with eye opening in response to

verbal command.

Light Sedation: -2 Awakens briefly (less than 10 seconds) with eye contact to verbal command.

Moderate Sedation: -3 Any movement, except eye contact, in response to command.

Deep Sedation: -4 No response to voice, but any movement to physical stimulation.

Unarousable Sedation: -5 No response to voice or physical stimulation.

Critical Care Skills/Standards of Care Identify nursing priorities/standards of care with these critical care interventions

Ventilator Management: Nursing Standards of Care: Rationale:

Arterial Line Nursing Standards of Care: Rationale:

Central Line/Dressing Care Nursing Standards of Care: Rationale:

Wound Vacuum Assisted Closure (VAC) Nursing Standards of Care: Rationale:

Part II: Put it All Together to Think Like a Nurse 1. Interpreting all clinical data collected, what are the current problems? Rank by priority. Which problem is most

serious? Why? (NCSBN: Step 3 Prioritize hypotheses)

Likely Problems: Rank by Priority: Rationale:

2. What is the pathophysiology of the priority problem? (NCLEX Management of Care/Physiologic Adaptation)

Priority Problem: Pathophysiology of Problem in OWN Words:

3. What body system(s) will you assess most thoroughly based on the primary/priority problem? Identify correlating

ORDER NOW FOR AN ORIGINAL PAPER!!! NSG 527-Initial Nursing Assessment DQ .

specific nursing assessments. (NCLEX Reduction of Risk Potential/Physiologic Adaptation)

PRIORITY Body System: PRIORITY Nursing Assessments:

Collaborative Care: Medical Management 4. State the rationale and expected outcomes for the medical plan of care. (NCLEX Pharm. and Parenteral Therapies) Initial Nursing Assessment DQ