Check the foley catheter to make sure it is not obstructed. Scene 6 Make sure O2 mask is secure and free of sputum. Instruct Lucy to assist in maintaining patient position and field sterility Insert foley catheter according to hospital recommended guidelines,to ensure sterility of catheter. Create sterile field with foley kit on the bedside table and don sterile gloves. Scene 5 Use therapeutic communication to explain necessary procedure. Obtain an order to insert a foley catheter. Notify family to self-isolate for 14 days Scene 4 Reorient patient to setting using therapeutic communication. Notify respiratory therapist to begin treatment. Change to simple O2 face mask per Healthcare provider Perform focused respiratory assessment. Give an SBAR to Hospitalist:Įducational need increased fall risk increased Health change increased neuro normal pain level normal patient needs increased Scene 2: Nursing concerns: Physiological FALSE Bleeding False Death anxiety TRUE Disturbed Body Image FALSE Esteem FALSE Impaired Acute Confusion FALSE Impaired Gas Exchange TRUE Ineffective breathing pattern TRUE Knowledge deficit TRUE Pain, Acute FALSE Physical Mobility, Impaired Skin Integrity FALSE Scene 3 Don appropriate PPE. Based on findings, nursing care actions that are most concerning are: Scene 7: Mr. Increased Respiratory rate of 32 and labored, peripheral edema +3 in both ankles and JVD. Repeat focused pulmonary assessment reveals profound bilateral atelectasis in the bases and frothy white sputum. Scene 6 UAP reports urinary output of 50 mL over the past three hours. Both nurses have donned appropriate PPE and have entered the room. Scene 5 Order for a foley catheter has been obtained and Lucy Jones, LPN, is there to assist. Just received an order to initiate 20 mg of Furosemide (Lasix) IVP, BID. He is on a 100% nonrebreather and he keeps pulling his mask off. In his confusion, he becomes combative and pulls out his IV. Raymond continues to deteriorate and becomes confused. He has bilateral lower lobe atelectasis with bronchial/vesicular wheezing. Vital Signs: BP is 92/58, Pulse 102, Respirations 30 and labored, Temperature 101.3, SaO2 91%. Scene 2: Select Nursing Concerns: Scene 3 The next day, he tests positive for COVID 19 and his condition has deteriorated as he is now in respiratory distress. The patient/family is fearing the worst due to COVID-19 Pandemic. Vital Signs: BP is 145/78, Pulse 89 Respirations 24 and slightly labored, Temperature 100.2 SaO2 94% on 2L nasal cannula. ![]() Raymond is receiving Furosemide (Lasix) 20 mg IV twice a day for pulmonary edema. Initially this cardiologist was concerned about congestive heart failure and Mr. He is on Claforan (cefotaxime) 2 g IV q4hr and sliding scale insulin. He is a retired postal worker who lives at home with his wife. He has a history of COPD, hypertension, diabetes type II, and a recent myocardial infarction. He has no other health concerns.Charlie Raymond, 65-year-old male who was admitted to a negative pressure room on Med-Surg for COVID precautions. He has a 20ga saline lock to his right hand, that was started in the ER. His pain has been well controlled with IV morphine 4 mg, written every 3 hours. His visual acuity is diminished, and the whites of his eyes are hemorrhaged. There is significant edema and discoloration to the left side of his face, and his left eye is almost completely swollen shut. They were not concerned as his intraocular pressure was normal in the ER. The maxillofacial surgeon was consulted, and they will see him this morning. He was unable to sleep later in the evening as the pain became worse, and his vision became more impaired. The patient stated that there was significant swelling, but his vision was fine, and the pain was controlled with beer and 800mg of ibuprofen. They applied some ice to his face, and he decided to go to the post game keg party instead of coming to the ER. ![]() Apparently, he was pitching, and the batter hit a line drive hitting him in the right side of the face. He was hit in the left eye by a softball yesterday. ![]() Wight Goodman, Patient was admitted to the floor last night from the ER for an orbital fracture.
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