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Part I: Emergency Department (ED)SKINNY ReasoningJohn Taylor, 68 years oldPrimary ConceptInfection/ImmunityInterrelated Concepts (In order ofemphasis)●Clinical judgmentNCLEX Client Need CategoriesCovered in Case StudyNCSBN Clinical Judgment ModelCovered in Case StudySafe and Effective Care EnvironmentStep 1: Recognize Cues✔●Management of Care✔Step 2: Analyze Cues✔●Safety and Infection ControlStep 3: Prioritize Hypotheses✔Health Promotion and Maintenance✔Step 4: Generate Solutions✔Psychosocial Integrity✔Step 5: Take Action✔Physiological IntegrityStep 6: Evaluate Outcomes✔●Basic Care and Comfort✔
●Pharmacological and Parenteral Therapies✔●Reduction of Risk Potential✔●Physiological Adaptation✔
Initial Triage Assessment in EDPresent Problem:John Taylor is a 68-year-old African-American male with a history of type II diabetes and hypertension who came to the emergency department (ED) triage window because he felt crummy; complaining of a headache, runny nose, feeling more weak, “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 worsen throughout the day. He has difficulty“catching his breath” when he gets up to go the bathroom. John is visibly anxious and asks, “Do I have that killer virusthat 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 beenmarried to Maxine, his wife of 45 years and is 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:current symptomatology: headache, runny nose, malaise, generalized weakness, muscle aches, fever and sweating, shortness of breath with exertion, anxiety, worsening nagging cough. Signs and symptoms may be indicative of COVID-19 but also match a variety of other ailments, anxiety could be contributing to shortness of breath. Uncontrolled diabetes may account for some symptomsRELEVANT Data from Social History:Clinical Significance:Active in church community, from large metropolitan area with confirmed cases of COVID-19Indicates that client may have had exposure to COVID-192.What additional clarifying questions does the triage nurse need to ask John to determine if his cluster of physical symptoms are consistent with COVID-19?