Activity Description Year Explained for Students (Easy Guide)
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Original Question
ACTIVITY DESCRIPTION Amy is a 51-year-old female who arrived in the ER department complaining of feeling dizzy and lightheaded. On assessment, she indicates lack of appetite, epigastric tenderness and ache, and a BP of 92/60. She feels dizzy and lightheaded with most movement, not just on rising or changing position. It is noted that she is limping slightly. She states she injured her knee when she slipped on some wet leaves on her porch. She has been taking analgesics for this. She was discharged from our Mental Health Unit three weeks after an unsuccessful suicide attempt with acetaminophen. HPI: Amy Cannelloni is a 51 yo Caucasian female with PMH significant for asthma, HTN, depression (admit 3 weeks ago for overdose) anxiety, obesity, and EtOH abuse presenting with epigastric/upper abdominal achy pain x several days, feeling lightheaded and dizzy Nursing Shift Report CHEMISTRIES: Na K Cl Cr BUN GLU 141 3.2 98 0.74 20 5.6 Alb AST ALT T. bili 3.4 38 27 0.8 HgB: 98 Neuro: awake, alert, and cooperative Resp: occasional wheeze heard, SaO2 95% on Room Air CV: BP a bit low on admission, am metoprolol held; pedal pulses present GI: abdominal pain, upper epigastric, tender and achy, constant, no appetite except sips of water for dry mouth, BS active, last BM 1 day ago, normal but dark GU: no problems, up to BR on own — note patient does get dizzy so reminded to sit on side of bed for 15 seconds prior to standing MSK: sore left knee – rated 4/10, mostly when standing on it, from previous fall last week, taking advil routinely for pain Skin: no problems Mental health: started Sertraline 3 weeks ago after overdose admission, mental health assessment not completed No IV Repeat CBC today at 1400 (ordered Q 12, but done quite early this am) AAT, VS Q4h but BP and P Q2 1. reasons that led to Amy coming to hospital and include the assessment findings of concern from the Emergency Department. 2. discusses why you think Amy is exhibiting these findings. In other words, think what might be going on based on symptoms. 3. Review the shift report. List four areas of nursing focus for your shift and discuss why you chose each as a priority. 4. The health care provider (physician) does rounds. Review the most recent written orders (check the times/dates). a. Explain to Amy what diagnostic test will be done in terms she can understand. b. What are the nursing responsibilities for this test (pre and post) relevant to Amy? 4. After lunch, the patient expresses nausea. List three nursing interventions that would be best to implement at this time? 5. A short time later, Amy vomits approximately 400ml coffee ground emesis with specks of bright red blood. a. What should the nurse do at this time? b. What orders would you anticipate from the physician at this time and why? 6. Look back to #1. Given the progress of the patient, would you change anything of what was written in #1? If so, rewrite Amy’s condition currently, including rationales.
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