Detail Clinical Significance Explained for Students (Easy Guide)
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Original Question
Detail Clinical Significance/Impact It is Tuesday afternoon (Time 1600), and you are working in an urgent care clinic. History of present illness: You are caring for Isaac, a 17- year-old male. He arrived from school complaining of shortness of breath. He says it started after completing a basketball game with his friends. He is afebrile and drove himself to the clinic. Allergies: NKDA Complains of SOB after playing basketball with his friends. This is a common symptom of asthma. Asthma is a common disease in children. Social History (from Isaac) Isaac lives home with his mother, father, and little sister. He is an honor-roll, senior student at the local public high school. He plays varsity basketball and enjoys fishing with his dad. He denies drugs, alcohol, or smoking. He has had some “trouble breathing” after sports for a few years but has never told his parents. He seemed shorter of breath and it would not stop this time, so he decided to come see a doctor. He has called his mother to come up to the urgent care clinic at this time. Denies drug, alcohol us or smoking Has had trouble breathing after sports for a few years but has never said anything about it. Untreated asthma could change the shape of an individuals airway which could reduce lung function. This time his SOB did not go away after a while, which could be a sign of exacerbation Medical History: tonsillitis Surgical history: tonsillectomy Tonsillitis could cause a a development of asthma Page Break Subjective History (from mom and Isaac) Clinical Significance/Impact Subjective History (from mother and Isaac): Isaac is well mannered and oriented. He does not get in trouble and has good grades. He has several scholarships to different universities and plans to attend a prestigious university to study biomedical engineering. His mother noticed he gets a little short of breath after sports, but it always goes away so she did not think it was a big deal. Isaac is up to date with vaccinations and primary care appointments. He does not take any RX medications. Mother notices he get SOB after sports but goes away after a while. He is not on any prescription medications Nursing Assessment: What assessment data is important and why? Respiratory assessment: Assess if there is EAE into the lungs. Note any wheezing or coughing, accessory muscle used***. Ensure adequate lung expansion Vitals assessment: looking at the his SPO2 to determine if enough oxygen is being delivered throughout the body especially the brain, as well as looking at the RR has it increased to try and take in more oxygen. Neurological assessment: to determine is the brain is getting enough oxygen. Note any neurological deficits due to a lack of oxygen to the brain Page Break Assessment Detail Clinical Significance/Impact Objective Data General Appearance: Isaac appears well but anxious. He is sitting on the edge of the exam table, feet dangling. He is using accessory muscles to breathe and seems a bit restless. Temp: 37.1°C (98.9°F) BP: 125/80 mmHg MAP 95 HR: 85 bpm RR: 32 SpO2: 88% on RA NEURO: alert and oriented to person/time/place/situation. GCS 15. PERRLA intact. CARDIAC: : Mucous membranes pink. Capillary refill < 3 seconds. Apical HRR. Peripheral pulses palpable X4 at +2. No edema. No murmur. RESP: Expiratory and inspiratory wheezes. Cough positive for mucus. Tachypnea with accessory muscle use. GI: Abdomen flat, soft, non-tender. NABS x4. GU: Voids painlessly and without hesitation. Urine clear, yellow. Musculoskeletal: Moves all extremities without overt deficits. Ambulates independently. Integumentary: Skin warm and dry to the touch. Psychosocial: Broad affect, pleasant mood. Mother is at bedside. Appears anxious and restless due to the inability to breathe properly Using accessory muscles to breathe, this is a secondary method to help try and bring more air into the lungs. RR: tachypenic because he is SOB is RR will increase to try and bring more oxygen into the lungs SpO2: hypoxic, the body is not getting enough oxygen Expiratory and inspiration wheezes: this is due to the narrowed airway due to a build up of What diagnosis do you suspect and why? Clinical Significance/Impact Page Break You receive the following orders from the provider. Clinical Significance/Impact Chest radiograph Arterial blood gas (ABG) WBC The RN receives the following orders from the provider. Clinical Significance/Impact Apply oxygen therapy as needed to keep Sp02 above 92% Monitor vital signs Administer short acting beta2 adrenergic agonist Diagnostic Test Results Clinical Significance/Impact Chest radiography Lungs clear, no atelectasis or infection. Arterial blood gas (ABG) pH: 7.35 PCO2: 30 mmHg HCO3: 25 mEq/L PO2: 70 mmHg O2 saturation: 88% RA Base excess: ±2 mEq/L WBC WBC: 10,000/mm3 Neutrophils: 25,000/mm3 Lymphocytes: 4,000/mm3 Monocytes: 600/mm3 Eosinophils: 500/mm3 Basophils: 100/mm3 RBC: 4.5 X 1012/L Hgb: 14 g/dL HCT: 40% Platelets: 300,000/mcL Family Education Clinical Significance/Impact What education is essential to communicate to Isaac about the possible triggers to his asthma attack? Case Study Continued Clinical Significance/Impact Isaac has received a breathing treatment with no improvement. He is being transferred emergently to the local hospital to be admitted to a medical unit. You prepare to call report to Paula, the inpatient RN. Isaac has received a SABA treatment with no relief. He is on 4L NC with an oxygen saturation of 92%. He needs a peripheral IV and cardiac monitor placed when he arrives at the hospital. His mother has left to go to the hospital so she can help receive him there. Considering Isaac's history, what information is important to include in handover? Practice using the SBAR format. Situation: Background: Assessment: Recommendation: Page Break What medication orders will Paula anticipate? Clinical Significance/Impact What is a potential complication when using inhaled corticosteroids? What nursing interventions will Paula implement and why? Administer medications Monitor vital signs Respiratory assessment Q4 hours Monitor telemetry Peak flow monitoring Test your knowledge! What are some complications of asthma? Page Break Discharge Instructions Clinical Significance/Impact You are preparing Isaac for discharge back home. He was in the inpatient medical unit for 3 days being treated for acute asthma exacerbation without infection. He received IV steroids, breathing treatments and oxygen therapy. He is on room air with Sp02 level of 100%. He reports feeling "much better". He is alert and oriented, has a good appetite, ambulates independently and is eager to be discharged home. His mother is at bedside to listen to the discharge instructions. Isaac was diagnosed with asthma and is going home on RX medications. He has follow-up appointments with his PCP and pulmonologist already scheduled. The following are prescription medications for Isaac at the time of discharge: Medication Dose Indication Proventil 2 puffs PRN and prior to exercise Short acting inhaler to relax smooth muscles in the airway Cromolyn sodium Nebulizer treatment daily Anti-inflammatory agents that stabilize mast cells Salmeterol 2 puffs inhaled daily Long term prevention of symptoms What instructions will be included for him and his mother at discharge?
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