95%(57)54 out of 57 people found this document helpful
This preview shows page 6 - 9 out of 9 pages.
2.What body system(s) will you assess most thoroughly performing a FOCUSED assessment based on the primary/priority problem? Identify correlating specific nursing assessments.(NCLEX: Reduction of Risk Potential/Physiologic Adaptation)PRIORITY Body System:PRIORITY Nursing Assessments:Respiratory fever (possible), cough, shortness of breath, chills, muscle pain, new loss of taste or smell, vomiting or diarrhea and/or sore throat. Current FOCUSED Nursing Assessment:GENERAL SURVEY:Appears anxious, body tenseNEUROLOGICAL:Alert & oriented to person, place, time, and situation (x4), generalized weaknessHEENT:Head normocephalic with symmetry of all facial features. Lips, tongue, and oral mucosa pink and moist.RESPIRATORY:Breath sounds fine dry crackles bilat. with diminished aeration on inspiration and expirationin all lobes anteriorly, posteriorly, and laterally, non-labored respiratory effort, episodic non- productive coughCARDIAC:No edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A-P-T-Mcardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees.ABDOMEN:DeferredGU:DeferredINTEGUMENTARY:Skin hot, dry, intact, normal color for ethnicity. Skin integrity intact, skin turgor elastic, no tenting present.3.What assessment data is RELEVANT and must be NOTICED as clinically significant by the nurse?(NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential Reduction of Risk Potential/Health Promotion & Maintenance)RELEVANT Assessment Data:Clinical Significance:
Cough, bilateral crackles, diminished aeration, feverFever and weakened pulmonary function could indicate infection by COVID-19
4.Interpreting clinical data collected, what problems are possible? Which problem is the PRIORITY? Why?(NCSBN: Step 2: Analyze cues/Step 3: Prioritize hypotheses/NCLEX: Management of Care)Problems:Priority Problem:Rationale:Decreased tissue perfusionineffective airway clearanceIneffective Airway ClearancePT is demonstrating decreased o2 saturation and bilateral crackles. If airway is not addressed, PT will likely develop secondary problems like infection orhypoxia related damage5.What nursing priority(ies) and goal will guide how the nurse RESPONDS to formulate a plan of care? (NCSBN: Step 4 Generate solutions/Step 5: Take action/NCLEX: Management of Care)Nursing PRIORITY:Ineffective Airway ClearanceGOAL of Care:Maintain airway patency, demonstrate improved oxygen exchangeNursing Interventions:Rationale:Expected Outcome:Assist client in airway clearance techniquesMonitor respirations and breath soundsObserve for signs/symptoms of infectionTo improve respiratory function and gas exchangeTo monitor for respiratory distress or accumulation of secretions