Fluid Overload NextGen SKINNY Reasoning- VERIFIED

Fluid Overload NextGen SKINNY Reasoning Anthony Robinson, 67 years old Primary Concept Perfusion/Gas Exchange Interrelated Concepts (In order of emphasis) • Clinical judgment NCLEX Client Need Categories Covered in Case Study NCSBN Clinical Judgment Model Covered in Case Study Safe and Effective Care Environment Step 1: Recognize Cues  • Management of Care  Step 2: Analyze Cues  • Safety and Infection Control Step 3: Prioritize Hypotheses  Health Promotion and Maintenance Step 4: Generate Solutions  Psychosocial Integrity Step 5: Take Action  Physiological Integrity Step 6: Evaluate Outcomes  • Basic Care and Comfort • Pharmacological and Parenteral Therapies • Reduction of Risk Potential  • Physiological Adaptation Present Problem: You are the nurse caring for Anthony Robinson, a 67-year-old African American male patient with a history of heart failure and iron deficiency anemia who was admitted to the medical floor from the emergency department earlier this morning for low hemoglobin. Mr. Robinson’s initial hemoglobin was 6.2 and the primary care provider ordered 2 units of packed red blood cells (PRBC). He received the first unit in the emergency department (ED) over 90 minutes and tolerated well with no change in status. Current Labs (ED): Complete Blood Count (CBC) WBC HGB Hct PLTs 7.5 6.2 34 154 Basic Metabolic Panel (BMP) + Mg Na K Cl CO2 BUN Creat. Gluc Mg 143 3.5 110 26 16 1.1 132 1.8 The second unit was started after he arrived on the floor and is nearly 2/3 finished. You are rounding on your other patients when Mr. Robinson presses his call light and states “I feel like I can’t catch my breath.” When you enter the room, you see Mr. Robinson in bed breathing rapidly and he appears anxious. 1. What data from the present problem is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: Hx of heart failure and iron deficiency anemia hgb- 6.2 hct- 34 Tachypnea (increase RR) -His hgb and hct levels are both low whoch is most likely due to the anemia but could also result from blood loss -Hgb is what transports O2 throuhgout the ody to the tissues, so with the hgb level being so low, it is of concern that there is not enough O2 being distributed throuhoughout the body. - Increase RR could be due to feeling anxious and trying to compensate for the feeling of not being able to catch his breathe Current VS: P-Q-R-S-T Pain Assessment: T: 98.2 F/36.8 C (oral) Provoking/Palliative: P: 102 (regular) Quality: Denies R: 28 (regular) Region/Radiation: BP: 138/89 Severity: O2 sat: 87% RA Timing: 2. What VS 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 from Present Problem: Clinical Significance: RR- 28 O2 sat- 87% pulse- 102 - He is tachypneic which could be due to lack of oxygen, or he could be holding onto too much CO2 in his body so his body is trying to get rid of CO2 -His O2 sat shows that he is struggling to breathe on room air which could again be realted to the low hgb numbers whihc arent allowing adequate oxygen to be distrubuted around the body -The increased pulse could be due to the heart trying to work harder to pump the smaller amount of hgb molecules throuhgout the body. Additional Information: • You put Mr. Robinson on supplemental oxygen via nasal cannula at 3 LPM. His O2 saturation improves to 92% and his respiratory rate is 24 breaths/minute. You listen to his lungs and note that they are clear in the upper fields with fine crackles bilaterally in the bases. His skin is cool, and moist. • A quick scan of the medical record shows a medical history of congestive heart failure. His home medications include metoprolol, lisinopril, furosemide, aspirin, and potassium chloride. You recall that Mr. Robinson told you earlier that he did not take his morning medications before coming to the emergency room. • The charted intake for the patient is 900 mL (300 PO fluids, 600 mL PRBC – 350 ml from the first unit, plus approximately 250 mL from currently infusing unit), the charted output is 200 mL clear yellow urine. • When he first arrived on the floor, he was breathing comfortably, RR 16, breath sounds clear throughout, and oxygen saturation 94% on room air. Pre-Transfusion VS: 15” After Transfusion: T: 98.4 F/36.8 C (oral) T: 98.2 F/36.8 C (oral) P: 98 (regular) P: 96 (regular) R: 18 (regular) R: 20 (regular) BP: 130/80 BP: 128/82 O2 sat: 94% RA O2 sat: 93% RA 3. What data from the additional information is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential) RELEVANT Data from Additional Info: Clinical Significance: Hx of CHF Skipped morning meds at home output less than input (fluid rentention) - CHF will affact the function of his heart and ability to pump blood through his body. Along with the low hgb and the lacking ability to pump blood throughout the body, his heart and body is working hard to get daily activites of life completed - the medications that he did not take this morning usually assist him in keeping his body at homestasis, so without the medications, his body has to work twice as hard to keep his body in balance 4. Interpreting clinical data collected, what problems are possible? Which problem is priority? Why? (NCSBN: Step 2: Analyze cues/Step 3: Prioritize hypotheses/NCLEX: Management of Care) Problems: Priority Problem: Rationale: ? -SOB, High, pt is having a hard time breathing could be due to blood transfusion or lack of hgb in the body -fluid rentetion, high, pt is not excreting enough fluid compared to what is being consumed. 5. What nursing priority will guide how the nurse RESPONDS to formulate a plan of care? (NCSBN: Step 4 Generate solutions/Step 5: Take action/NCLEX: Management of Care) Nursing PRIORITY: Increase pt diuresis Nursing Interventions: Expected Outcome: Monitor vital signs diruetics Strrict I's & O's - mintoring the pulse and respirations secifically to see if they trend back down to expected ranges -administer diuretics, most likely via IV to increase urine output so the body is not continuosly retaining so much fluid and putting a lot of stress on the heart. -monitoring pt intake and output to see if there is any improvment of the fluid output and see if there is a decrease in the fluid retention. Situation: Name/age: Anthony Robinson/ 67 y.o. BRIEF summary of primary problem: Pt has hx of CHF with lab values of hgb and hct low upon arrival and 2 units of PRBCs were adminstered. 2nd unit was nearly finisehed and pt complained of SOB. Pt is tachypneic and tachycardic as well as showing signs of fluid rentention. Background: Primary problem/diagnosis: Fluid overload RELEVANT past medical history: CHF and Iron defincieny anemia RELEVANT background data: 67 y.o., low hgb and hmc levels upin admittance, received 1 full unite of PRBCs with no issse and received 2/3 of 2nd unit before c/o SOB. Pt did not take morning meds at home. Assessment: Vital signs: T:98.2 F, HR:96, RR:20, BP:128/82, O2 sat 93% on 2L O2 RELEVANT body system nursing assessment data: upper lung fields clear w fine crackles bilaterally at the lung bases RELEVANT lab values: Stops the PRBSc infusion and kept pt in upright postion. monitroed pt VS. pt is responding well to care and breathing has become more effortless How have you advanced the plan of care? Patient response? and patients appear more at ease. INTERPRETATION of current clinical status (stable/unstable/worsening): Stable. Recommendation: Suggestions to advance plan of care: Administer diuretics. and adminster meds to decrease HR and stress on the heart, 6. After implementing the plan of care, EVALUATE your patient by INTERPRETING relevant clinical data to determine if patient status is improving, declining, or reflects no change. (NCSBN: Step 6 Evaluate outcomes/NCLEX: Management of Care) Assessment Finding: Improving: Declining: No Change: Urine output: 750 mL X HR: 92/minute X RR: 20/minute non-labored X BP: 120/74 X O2 sat: 95% room air X Crackles persist in bases but not as pronounced X Resting comfortably-appears less anxious X