Mr. John Hayes has been admitted to the emergency department after a car accident. His details are:
Age 68, T 36.5, P96, RR 28, BP 160/95, oxygen sats 92%, Pain score 9/10. He has pain over his left chest and decreased air entry to his left chest. His GCS is 15. He had no LOC and was able to extricate himself from the car. The airbags had inflated.
Johns' weight is 130kgs. John is married to Beryl aged 65 years. They live in a high set house and struggle to get up and down the stairs into the house. They have 2 sons who live nearby and visit regularly. Both John and Beryl have poor eyesight and wear glasses.
John has been x-rayed and this has been assessed by the doctor.
This case study requires you to:
Apply evidence-based principles to correctly assess this patient. Detail the types of assessment you would do now for this patient in their current state. Use a systems framework to do this. eg CNS, CVS, Respiratory, Abdo, renal and social/ other.
Describe the urgent appropriate care for this patient, being aware of the prioritization needed. You need to cover the care for the first 1-2 hours only.
Use the nursing process framework:
Assessment: CNS; RESP; CVS; GIT; RENAL; Other
No need for planning at this time.
For the CNS: pt alert and orientated, no loc, pain over l) side chest on inspiration, pain score 9/10, cyanosis due to decrease in blood oxygen levels.
Resp: oxygen therapy to prevent hypocrisy 2l via nasal canala. Tachypnea and dyspnea with increased work of breathing due to reduced lung expansion on l) side. Use of accessory muscles. Chest asymmetry shift on palpitation. Decreased breath sounds on l) side Jeni thorax on auscultation. L) side hyper resonance on percussion. Needle aspiration to remove excess air with needle inserted into second intercostal space, at midclavicular line or chest tube to decrease chest if pt deteriorates. Pt placed in semi Fowler's position to promote air exchange, ease of breathing and comfort. Deep breathing through spirometry use and coughing encouraged to expand lungs.
CVS: hypertensive. Tactile fremitus decreased due to vibrations from larynx to chest surface being impeded by pneumothorax. Cap refill <2. Arterial blood gas or venous blood gas to check if pt can compensate own own. Ecg to assess heart action.
Other: anxious and fatigued. Gait unsteady. Wears glasses. Family notified.
As you can see I am not sure what information from above should rather go into diagnosis or/and intervention /implementation.
Very nice assessment but does your instructor want nursing interventions or medical interventions?
Do you use the PERSON format for nursing diagnosis? If so think psychosocial, safety, oxygenation and nutrition. Four easy ones right there.
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