Mobility VCBC Post Work (Nusrsing)

This is a Unfolding Case Study
Patient Details:
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Case Study History
Name:
James, Karen
Age:
57  Years
Gender:
Female
  
Karen James is a 57-year-old female who was admitted to the medical-surgical unit from her primary care physician’s office for treatment and evaluation of persistent and worsening influenza. She has a past medical history of asthma as well as depression and anxiety.
You are currently working on Phase 1. You have completed Phase 0 of this scenario.
Patient Details:
Print Phase Info
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Case Study History
Name:
James, Karen
Age:
57  Years
Gender:
Female
Phase
1,
Wednesday
16:00
  
You have assumed care for Ms. James who is admitted to the medical-surgical unit for rehydration and management of respiratory distress.

 
Orient yourself to the patient and health record by locating the following pieces of information within the System Assessment Report and Patient Teaching, and type your answers in a Miscellaneous Nursing Note:

 
1). Run a report on all the System Assessments documented for the patient in the last 24 hours. You will need to go to Patient Charting System Assessments Show Saved Charting. What was documented for the respiratory effort? What was auscultated in the Lower Right Posterior lobe of the lungs? What was documented related to tissue perfusion?

 
2). What was the last documented temperature for Karen?

 
3). Does Ms. James use any sensory aides?

 
4) What does she rate her pain?

 
5) What is her MORSE Fall Risk Score?

 
Review the client’s History and Physical, what indications can you see place this patient at risk for mobility issues or falls?

 
[LEARNER ACTION: In a misc nursing note identify risks for mobility and falls. Explain her score on the MORSE scale.]

 
When you are finished with this task, you may click Complete this Phase.
Patient Information
  
Chief Informant:
Patient
Chief Complaint:
Shortness of breath, productive cough
History of Current Problem:
Patient states she has had 3-week history of influenza. Has now developed a severe cough approximately 3 days ago with shortness of breath. Unable to sleep due to cough, which often causes bronchospasms. Patient also complains of fever, fatigue, and right-sided chest pain. Seen in urgent care 3 days ago and given Z-pack. No improvement in symptoms.
Allergies:
None known
Family History:
Mother died at age of 72 with breast cancer. Father is alive at the age of 79 and has congestive heart failure.
Past Medical History
  
Previous Illnesses:
Patient has asthma. Also states she gets bronchitis every 1-2 years.
Contagious Diseases:
None
Injuries or Trauma:
None
Surgical History:
Tonsillectomy and adenoidectomy as a child.
Dietary History:
Regular diet. Patient is 5’1″ and 140 pounds. Has recently lost 20 pounds on Weight Watchers diet.
Other:
—
Social History:
No smoking, no drugs. Uses alcohol in social situations.
Current Medications:
Tylenol 650 mg PO every 4 hours PRN pain or fever

Prozac 20 mg PO every day

Xanax 0.25 mg PO every 8 hours PRN

Xopenex HFA 2 puffs every 6 hours PRN
Review of Systems
  
Integument:
Denies complaints.
HEENT:
States she had neck soreness related to influenza, with “swollen glands.”
Cardiovascular:
No complaints.
Respiratory:
Complains of shortness of breath, frequent productive cough. States her cough often turns into bronchospasms. Uses inhaler, peppermint tea, lozenges, and Vicks VapoRub.
Gastrointestinal:
Complains of decreased appetite.
Genitourinary:
No complaints.
Musculoskeletal:
Complains of generalized body aches.
Neurologic:
Alert and oriented.
Developmental:
Denies complaints.
Endocrine:
No complaints.
Genitalia:
No complaints.
Lymphatic:
No complaints.
Physical Exam
  
General:
57-year-old female in mild distress. Appears weak.
Vital Signs:
Temp: 103.2 F, Pulse: 114, Resp: 28, Blood pressure: 154/78 in office this morning
Integument:
Skin clear of rash.
HEENT:
Pupils equal and reactive. Nasal congestion. Neck supple.
Cardiovascular:
S1, S2, no murmur.
Respiratory:
Lungs clear with crepitation in right base.
Gastrointestinal:
Abdomen soft, active bowel sounds.
Genitourinary:
—
Musculoskeletal:
Moves all extremities well.
Neurologic:
Alert and oriented.
Developmental:
—
Endocrine:
—
Genitalia:
Not assessed. Seen by gynecologist recently. Negative pap smear and negative mammogram.
Lymphatic:
No lymph node swelling at this time.
Impressions:
Pneumonia
Plan:
The patient is admitted for IV antibiotics and close observation of respiratory status. Patient will need influenza and pneumonia vaccines.
Provider Signature:
Michael Foster, MD
Day:
Wednesday
Time:
12:45
Chief Complaint:

The patient is a 57-year-old female admitted today for chief complaint of shortness of breath.

 
Patient’s labs were completed in the primary care provider’s office prior to admission and results include the following:

WBC: 20.2 x 109/L

RBC: 4.51 RBC x 106/ul

Hemoglobin: 14.0 g/dL

Hematocrit: 40.2%

Sodium: 139 mEq/L

Potassium: 4.2 mEq/L

Chloride: 105 mEq/L

CO2: 26 mEq/L

Glucose: 91 mg/dL

BUN: 17 mg/dL

Creatinine: 0.5 mg/dL

 
She is also febrile at 102.7.

Nursing will initiate IV antibiotics.
Showing 1 to 1 of 1 entries
FirstPrevious1NextLast
   
Chart Time

Temp

Resp

Pulse

BP

Sat%

Notes

Entry By

 
Wed 12:45

102.7

22

112

142/77

98

C Diaz, RN

Select Chart Type:       Temperature Respiration Pulse Blood Pressure Oxygen Saturation 

Select and drag to zoom in on a date range
102.7F/39.3C

Patient Card
   
Order Day/Time

Description

Category

Last Performed

Discontinue
 
Wed | 13:00

Admit   to medical-surgical

Alerts

—

 
Wed | 13:00

Start and maintain IV line

IV

—

 
Wed | 13:00

Pulse oximetry every 4 hour(s)

Respiratory

—

 
Wed | 13:00

Vital signs every 4 hours

Vital Signs

—

 
Wed | 13:00

Up as tolerated

Activity/Mobility

—

 
Wed | 14:00

Diagnosis-Respiratory   distress syndrome-ADDED-Disease Process

Patient Teaching

—

 
Wed | 13:00

Regular/General   Diet

Diet

—

Showing 1 to 7 of 7 entries
FirstPrevious1NextLast
PRN
   
Drug Name

Order Start

Order Stop

Dose

Route

Frequency

Dosage Time

Action
 
Acetaminophen Tablet –   (Tylenol, Genapap)

Wed   13:00

Tue   23:59

650   mg

Oral

Every   6 Hours PRN

 –   –

 
Levalbuterol Nebulizer   Solution – (Xopenex Nebulizer Solution)
Chart:
System Assessments Wed 13:00
Entry Time:
Wed 13:00
Entered By:
C Diaz, RN
Cardiovascular Assessment
  
Pulses
  
Apical:
Regular
Tissue Perfusion
  
Peripheral vascular, general:
Warm extremities
Edema
  
No edema noted
Cardiac Assessment
  
No cardiac problems noted
Respiratory Assessment
  
Productive Cough Secretions Assessment
  
Color:
Green
Amount:
Scant
Cough
  
Cough strength:
Strong
Cough type:
Productive
Oxygenation
  
Respiratory/breathing support:
Nebulizer treatment
Lower Right Posterior
  
Auscultation:
Coarse crackles
Lower Left Posterior
  
Auscultation:
Diminished
Upper Right Posterior
  
Wheeze Description:
Expiratory
Auscultation:
Wheeze
Upper Left Posterior
  
Wheeze Description:
Expiratory
Auscultation:
Wheeze
Productive Cough Secretions Assessment
  
Consistency:
Thick
Secretion odor:
None
Upper Left Anterior
  
Auscultation:
Clear
Upper Right Anterior
  
Auscultation:
Clear
Respiratory Effort
  
Dyspnea/shortness of breath
Shortness of breath on exertion
Respiratory Pattern
  
Labored
Neurological Assessment
  
Level of Consciousness/Orientation
  
Oriented to person, place, time, and situation
Emotional State
  
Calm
Cooperative
Central Nervous System Assessment (CNS)
  
No CNS problems evident
Integumentary Assessment
  
Integumentary Assessment
  
No assessment required at this time
Sensory Assessment
  
Vision Assessment
  
Wears glasses
Wears contacts
Musculoskeletal Assessment
  
Range of Motion (ROM)
  
Moves all extremities with full range of motion
Gastrointestinal Assessment
  
Abdomen
  
Abdominal assessment:
Soft to palpation
Gastrointestinal
  
No gastric problems noted
Intestinal
  
Date of last bowel movement:
Monday
Continence of bowel:
Continent
Intestinal assessment:
No bowel problems noted
Bowel sounds:
Active x 4 quadrants
Rectum:
No reported rectal problems
Pain Assessment
  
Do You Have Pain Now?
  
No
Genitourinary Assessment
  
Genitourinary Assessment
  
No assessment required at this time
Psychosocial Assessment
  
Psychosocial Assessment
  
No assessment required at this time
Safety Assessment
  
Orientation
  
Oriented to time, person, place
Fall Risk
  
30
Bracelet Check
  
Hospital ID bracelet
Safety Notes
  
Low fall risk
Morse Fall Scale
  
History of Falling
  
No=0
Secondary Diagnosis
  
No=0
Ambulatory Aid
  
None/Bedrest/Nurse Assist=0
IV or IV Access
  
Yes=20
Gait
  
Weak=10
Mental Status
  
Oriented to Own Ability=0
Total Fall Risk Score
  
Risk Score:
30
Fall Risk Score and Preventative Measures Implemented
  
Fall Risk Level:
Medium Risk
Fall Risk Measures:
Implement