NUR 4153-Deliverable 4-Make the Best Choice for the Right Situation

NUR 4153-Deliverable 4-Make the Best Choice for the Right Situation

The six nursing interventions I believe to be appropriate and should be completed in this order within the next one hour:

Administer 2mg Morphine IV now for breakthrough pain

Call the physician to get an order for a Nicotine Patch, and report decreased urinary output with amber urine

Input consult for pain management into the electronic order system

Apply anti-embolism stockings bilaterally

Administer tetanus immunization

Decrease O2 to 2L Nasal Cannula and continue Sp02 monitoring

What is the best action to perform first from the six actions identified as part of planned client care for this client?

Administer 2mg Morphine IV now for breakthrough pain

Notice: The patient is stating his pain is 8/10. The patient just went through a traumatic accident and is status post-surgery.

Interpret: The patient is in pain at this time, which is considered a breakthrough.

Pain is subjective.

Reflect: Once his pain is under control, pain management can be evaluated, the PCA pump can be discontinued, and oxygen needs may decrease due to a decrease in pain and an increase in relaxation and focus on breathing techniques (Walid, 2008).

What is the best action to perform the second of the six actions identified as part of planned client care for this client?

Call the physician to get an order for a Nicotine Patch, and report decreased urinary output with amber urine.

Notice: The patient is demanding a cigarette, and his main focus appears to be on having a smoke rather than his vitals, oxygen, or stockings. The urine bag should have more output than 40cc, and the color should be amber.

Interpret: Smoking is this patient’s. We can use this to cluster-call information to the physician inquiring about a Nicotine Patch order and the decrease in urine output and color. The decrease in urine output and the dark coloring could be an indication of kidney injury from the motor vehicle accident.

Respond: Call the physician for an order for a Nicotine Patch and report the decrease in urine output, stressing that this patient was just in a motor vehicle accident and underwent

Reflect: Even though smoking or nicotine decreases wound healing and can lead to poor circulation, the patient is worked up over not having nicotine in his body at this time. This places the client at risk of elevating his blood pressure and could lead to the formation of embolisms and strokes. Suppose the patient is able to have nicotine relief. In that case, their pain levels and what appears to be agitation at this time should decrease, causing blood pressure to decrease, oxygen saturation to increase, and pain to decrease (Bender, D., 2014). The patient was just in a motor vehicle accident that left him with multiple injuries to the abdominal area Kno. Wing, the trauma to this area can lead to kidney injury; an assessment of the kidneys should be ordered and done via lab draws and urine tests (Perkins, Z., 2019).

NUR 4153-Deliverable 4-Make the Best Choice for the Right Situation

What is the best action to perform a third of the six actions identified as part of planned client care for this client?

Input consult for pain management into the electronic order system

Notice: The physician has placed an order to decrease the PCA pump and to have a pain management consult with the

Interpret: We need to have a plan developed for pain management for the patient as the PCA pump is being discontinued. Since we are potentially placing an order for the patient’s Nicotine Patch and writing a communication note for the patient’s chart, we can quickly add these changes to the patient.’

Respond: Place the orders for a pain management consult and then disconnect the PCA pump.

Reflect: As the patient has just received a dose of Morphine for breakthrough pain, the patient should have controlled pain long enough for pain management to come and consult with him. Having a pain management consult will help determine the medication that would most benefit the patient in his recovery, as well as determine the severity of the patient’s acute and chronic pain needs. Establishing pain management now will decrease the time the patient will be without assistance during his recovery (Walid, 2008).

What is the best action to perform fourth of the six actions identified as part of planned client care for this client?

Administer tetanus immunization

Notice: The patient was in a motor vehicle accident with a rollover, which caused multiple abrasions, rib fractures, and a right femur fracture (Tetanus vaccines: WHO position paper 2017).

Interpret: We need to administer the tetanus shot to the patient to prevent the development of tetanus infection, which could lead to muscle pain, contractions, and weakness, and if left untreated, could lead to respiratory complications and death.

Respond: Educate the patient on the need for tetanus immunization, explaining why the doctor has ordered it, what it prevents, symptoms and outcomes of tetanus if the patient becomes infected, mortality rate, and how the medication is administered, obtaining consent to the injection as well. Once consent is obtained, administer the shot.

Reflect: The administration of the tetanus vaccine is important due to the amount of external to internal injuries this patient has. Coming into contact with multiple materials during a motor vehicle accident, as well as surgical sites that, are all points of entry for tetanus. If not prevented by immunization or booster, infection could lead to muscle aches and cramps and contractions in the neck and jaw and eventually affect breathing, potentially leading to death. The patient is at a lower risk of acquiring tetanus if given the vaccine. Currently, tetanus has no cure, and is care of the infection is focused on managing the symptoms. However, the vaccine is the easiest way to prevent infection (Johnston, L. 2011).

What is the incorrect action for this client?

Decrease O2 to 2L Nasal Cannula and continue Sp02

The patient has an oxygen saturation of 94% while on oxygen at 4L nasal cannula. If we decrease his oxygen to 2L at this time, his oxygen saturation will fall and will not stay at the guideline of 92%. Maintaining proper oxygen flow and monitoring Sp02 levels, we can also monitor the patient’s remaining ABGs. Currently, the patient is in respiratory acidosis uncompensated, so if we decrease his oxygen before monitoring and ensuring the patient has within normal limits or stable ABGs, we are increasing the risk of the patient maintaining respiratory acidosis, which could lead to respiratory failure, poor organ function, and shock. Education on smoking cessation and materials on where to get assistance in smoking cessation should be provided to the patient. The use of oxygen should be titrated down slowly to assess oxygen saturation without dropping the patients’ oxygen levels too quickly while maintaining ABG levels within normal parameters. If we are able to decrease the patients’ pain, we can provide deep breathing techniques not only for pain relief measures but for increasing oxygen saturation levels as well (Grensemann, J., 2018).

References

Bender, D., Jefferson-Keil, T., Biglari, B., Swing, T., Schmidmaier, G., & Moghaddam, A. (2014). Cigarette smoking and its impact on fracture healing. Trauma, 16(1), 18–22. https://doi.org/10.1177/1460408613504064

Grensemann, J., Fuhrmann, V., & Kluge, S. (2018). Oxygen Treatment in Intensive Care and Emergency Medicine. Deutsches Arzteblatt International, 115(27–28), 455–462. https://doi.org/10.3238/arztebl.2018.0455

Johnston, L. (2011). Tetanus, diphtheria, and pertussis: ancient diseases in modern times. Professional Nursing Today, 15(2), 20–26.

Perkins, Z. B., Captur, G., Bird, R., Gleeson, L., Singer, B., & O, B. B. (2019). Trauma-induced acute kidney injury. PLoS ONE, 14(1), 1–14. https://doi.org/10.1371/journal.pone.0211001

Tetanus vaccines: WHO position paper, February 2017 – Recommendations. (2018). Vaccine, 36(25), 3573–3575. https://doi.org/10.1016/j.vaccine.2017.02.034

Walid MS, Donahue SN, Darmohray DM, Hyer LA Jr., & Robinson JS Jr. (2008). The Fifth Vital Sign — what does it mean? [corrected] [published erratum appears in PAIN PRACTICE 2009 May-Jun;9(3):245]. Pain Practice, 8(6), 417–422. https://doi.org/10.1111/j.1533-2500.2008.00222.x

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NUR 4153-Deliverable 4-Make the Best Choice for the Right Situation

Determine appropriate responses when integrating situated cognition into clinical reasoning.

Scenario

One week ago, you started your dream job as an orthopedic nurse at a Level 1 Trauma Center in a metropolitan city of 3.7 million people. The hospital has been ranked as the #5 Trauma Orthopedic Specialty Unit in the United States for eight years. At this point during orientation, you are permitted to care for one stable client per 12-hour shift. Today, you start your shift with Ryan, a 25-year-old admitted through the Emergency Room after a motor vehicle accident with rollover resulting in a fractured right femur, multiple rib fractures, sternal bruises, and multiple abrasions. He is two hours post-op from an open reduction internal fixation of the right femur and appears alert and oriented. When you enter the room, his first statement is, “Can someone please get me a cigarette or a patch; I have not had a smoke since yesterday morning!”

Assessment Data:

The client is sitting up in bed with thigh-high anti-embolism stockings on the left leg only.

Dressings to multiple abrasions appear dry.

Urine in Foley Bag amber colored, and urinary output in the past 2 hours 40cc

Pain reported as eight on a scale of 10 with a goal of 5

Vital signs:

BP 130/80

Heart Rate 92

O2 Sats 94% on 4L Nasal Cannula

Blood Gases:

pH 7.32

PaCO2 53 mmHg

HCO3 22mmol/L

Pao2 84mm Hg

Physician’s Orders:

Bed Rest Only

Clear Liquid Diet

Oxygen to maintain Spo2 of 92% or greater

ABGs are repeated every 4 hours

Discontinue PCA and consult pain management

Administer tetanus and flu immunizations before discharge

Administer 1-2mg Morphine IV every 4-6 hours as needed for breakthrough pain

As you review the assessment data and physician orders, you plan client care and determine six nursing interventions you believe are appropriate and should be completed in this order within the next hour:

Administer 2mg Morphine IV now for breakthrough pain

Apply anti-embolism stockings bilaterally

Call the physician to get an order for a Nicotine Patch, and report decreased urinary output with amber urine.

Input consult for pain management into the electronic order system

Decrease O2 to 2L Nasal Cannula and continue Sp02 monitoring

Administer tetanus immunization

Instructions

As you write down the proposed interventions, the nurse manager stops by to check on your progress and asks you a few questions regarding your decisions. The nurse manager is disappointed and states, “One of these actions is not correct I want you to write down what you believe is the best choice from your list to do immediately and the action you believe is incorrect and should not be done. I will be back in 10 minutes to discuss your thoughts.”

On a document, provide detailed responses to these questions:

What is the best action to perform first from the six actions identified as part of planned client care for this particular client?

What is the best action to perform the second of the six actions identified as part of planned client care for this particular client?

What is the best action to perform a third of the six actions identified as part of planned client care for this particular client?

What is the best action to perform fourth of the six actions identified as part of planned client care for this particular client?

What is the incorrect action?