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PRIORITY Patient Activity Part I: Who does the nurse see first?
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PRIORITY Patient Activity Part I: Who does the nurse see first?
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PRIORITY Patient ActivityPart I: Who does the nurse see first?
Herbie Saunders, 62 years old David Mueller, 71 years old Gladys Parker, 92 years old
CHF Exacerbation Below-the-Knee Amputation Weakness and Falls
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory Case Study
Safe and Effective Care Environment
Management of Care 17-23%
Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12%
Psychosocial Integrity 6-12%
Physiological Integrity
Basic Care and Comfort 6-12%
Pharmacological and Parenteral Therapies 12-18%
Reduction of Risk Potential 9-15%
Physiological Adaptation 11-17%
© 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in
retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying,
recording or otherwise, without the prior written permission of KeithRN
, Part I-Patient Care Scenarios
You are the RN on a busy medical-surgical/telemetry floor at Anytown General
Hospital. Each nurse on your unit typically cares for 3-5 patients.
You have just arrived for your day shift and are receiving nurse-to-nurse reports
from three different night shift nurses. After you receive reports, you will have
an opportunity to review the current orders for each of your patients.
NOC Nurse Report
Patient #1: Herbie Saunders
Patient Report: What Do You Notice? Clinical Significance:
“Herbie Saunders is a 62-year-old male who came in last - Occasion - CHF
night for a CHF exacerbation. His doctor is Dr. Davis exacerbation
and he’s a full code. He’s alert and oriented and can al PVC
make his needs known. He’s on tele, normal sinus - Full code can cause
rhythm with occasional PVCs. His pressures are fine, pulmonary
heart rate is in the 70s. Lungs are clear in the uppers with
edema,
crackles in the bases. - Coughing up
possible
He’s coughing up a small amount of white frothy a small
secretions. He’s been on room air since he arrived, abnormal lungs
oxygen sats are in the low-mid 90s. He got 40 mg IV amount of sounds due to
Lasix last night in the ED; I think you might have white frothy white frothy
something scheduled during your shift but I haven’t
given anything overnight. He has a 20 gauge in his right secretions. secretions.
forearm. I’m not sure how he gets around since he’s been Possible
in bed since he got here.”
- 40 mg IV infection.
Most Recent Vital Signs @ 0357 What Do You Notice? Clinical Significance:
Lasix
-- 20
O2 gauge
sat is
T: 98.6 F (oral)
- Low O2 sat;
P: 76
low (92% pt needs
R: 20
RA) oxygen
BP: 128/87 (MAP 101 mmHg)
- Monitor
O2 sat: 92% on room air
- Weight is weight; could
Pain: denies
196 lb (89.1 be due to fluid
Admission Weight: 196 lb (89.1 kg)
In one sentence, describe the ESSENCE of the patient scenario that will guide your plan of
I will provide O2 for the patient and comfort (different positions), as well as assessing his lungs
due to the frothy secretions.
care? What questions do you have for the nurse?
Is the patient able to eat? What time did you check the patient’s weight? What is the output of the
patient after administering Lasix?
© 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in
retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying,
recording or otherwise, without the prior written permission of KeithRN
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