Unfolding clinical reasoning case study answers

Novel Coronavirus Disease (COVID-19) UNFOLDING Reasoning John Taylor, 68 years old Primary Concept Immunity Interrelated Concepts (In order of emphasis) • Clinical judgment • Communication NCLEX Client Need Categories Safe and Effective Care Environment • Management of Care • Safety and Infection Control Health Promotion and Maintenance Psychosocial Integrity Physiological Integrity • Basic Care and Comfort • Pharmacological and Parenteral Therapies • Reduction of Risk Potential • Physiological Adaptation Covered in Case Study ✓ ✓ ✓ ✓ NCSBN Clinical Judgment Model Covered in Case Study Step 1: Recognize Cues Step 2: Analyze Cues Step 3: Prioritize Hypotheses ✓ ✓ ✓ Step 4: Generate Solutions Step 5: Take Action Step 6: Evaluate Outcomes ✓ ✓ ✓ ✓ ✓ © 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: Initial Nursing Assessment Present Problem: John Taylor is a 68-year-old African-American male with a history of type II diabetes and hypertension. He came to the emergency department (ED) triage window because he felt crummy, complaining of a headache, runny nose, feeling weaker, “achy all over” and hot to the touch and sweaty the past two days. When he woke up this morning, he no longer felt hot but began to develop a persistent “nagging cough” that continued to get worse throughout the day. John is visibly anxious and asks, “Do I have that killer virus that I hear about on the news?” Personal/Social History: John lives in a large metropolitan area that has had over three thousand confirmed cases of COVID-19. He has been married to Maxine, his wife of 45 years, and is a retired police officer and active in his local church. 1. What data from the histories are 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: RELEVANT Data from Social History: Clinical Significance: 2. What additional clarifying questions does the triage nurse need to ask John to determine if his cluster of physical symptoms is consistent with COVID-19? 3. Based on the clinical data collected, identify what measures need to be immediately implemented using the following clinical pathway. 4. What type of isolation precautions does the nurse need to implement if COVID-19 is suspected? What specific measures must be implemented to prevent transmission? Type of Isolation: Implementation Components: © 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 II: Patient Care Begins in the ED: John is brought back to a room. As the nurse responsible for his care, you collect the following clinical data: Current VS: T: 100.3 F/38.8 C (oral) P: 118 (regular) R: 22 (regular) BP: 164/88 MAP: 113 O2 sat: 92% room air P-Q-R-S-T Pain Assessment: Provoking/Palliative: “moving makes it worse” “achy” Quality: “all over” Region/Radiation: 5/10 Severity: continuous Timing: 1. What VS data are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential /Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: