John Washington, 14 years old Primary. Concept Inflammation Interrelated Concepts (In order of emphasis) • Pain • Stress • Clinical Judgment • Patient Education • CommunicationAppendicitis/Appendectomy RAPID Reasoning Suggested Answer Guidelines. 100%.

Document Content and Description Below

Appendicitis/Appendectomy RAPID Reasoning Suggested Answer Guidelines John Washington, 14 years old Primary Concept Inflammation Interrelated Concepts (In order of emphasis) • Pain • Stres... s • Clinical Judgment • Patient Education • Communication NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment ✓ Management of Care 17-23% ✓ ✓ Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12% ✓ Psychosocial Integrity 6-12% ✓ Physiological Integrity ✓ Basic Care and Comfort 6-12% ✓ ✓ Pharmacological and Parenteral Therapies 12-18% ✓ ✓ Reduction of Risk Potential 9-15% ✓ ✓ Physiological Adaptation 11-17% ✓1 History of Present Problem: John Washington is a healthy 14-year-old African American male who weighs 150 lbs. (68.2 kg). He came to the emergency department because he woke up this morning at about 2 am with "excruciating" generalized abdominal pain around his belly button that has been progressively getting worse over the past several hours. It is now 2 pm. He took ibuprofen 400 mg PO this morning, which decreased the pain some but is now more painful and uncomfortable. The pain is now localized to his RLQ. The pain increases with walking and movement but he feels better when he lies down in a fetal position. He vomited three times after he drank some orange juice for breakfast this morning and has had nothing to drink since. He continues to feel nauseated but has not had an emesis since this morning. Personal/Social History: John lives with his mother and three younger brothers. He is active in athletics and has a strong social network of friends and family in the inner-city neighborhood where he lives. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT Data from Present Problem: Clinical Significance: Woke up this morning at about 2 am with "excruciating" generalized abdominal pain the past several hours that has been progressively getting worse. He took ibuprofen 400 mg PO this morning, which decreased the pain some but is now more painful and uncomfortable. The pain is now localized to his RLQ. The pain increases with walking and movement but feels better when he lies down and lies in a fetal position RELEVANT Data from Social History: Clinical Significance: He is active in athletics and has a strong social network of friends and family in the inner-city neighborhood where he lives. What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) Initial Assessment by Primary Nurse What body system(s) will the nurse most thoroughly assess based on the problem and the clinical data collected to this point? (Reduction of Risk Potential/Physiologic Adaptation) PRIORITY Body System(s): PRIORITY Nursing Assessments: Abdomen/GI Current Assessment: GENERAL SURVEY: Alert, oriented, pleasant, appears tense, uncomfortable, dress appropriate for the season, hygiene and grooming normal for age and gender. NEUROLOGICAL: Alert & oriented to person, place, time, and situation (x4) HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and moist. RESPIRATORY: Breath sounds clear with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort on room air. CARDIAC: Pink, warm & dry, 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-M cardiac landmarks with no abnormal beats or murmurs. ABDOMEN: Abdomen round, rebound tenderness in RLQ to gentle palpation. Rebound tenderness present in RLQ, BS + in all four quadrants, bowel sounds diminished/hypoactive GU: Voiding without difficulty, urine clear/dark amber What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion & Maintenance) RELEVANT Assessment Data: Clinical Significance: GENERAL SURVEY: Appears tense, uncomfortable ABDOMEN: Abdomen round, tenderness in RLQ to gentle palpation. Rebound tenderness present in RLQ. GU: Voiding without difficulty, urine clear/dark amber Radiology Reports: What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: These labs are ALWAYS RELEVANT, therefore they must be intentionally noted by the nurse! WBC: 14.5 Hgb: 15.2 Platelets: 245 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: These labs are ALWAYS RELEVANT, therefore they must be intentionally noted by the nurse! Sodium: 133 ********************************** CONTINUED IN THE ATTACHMENT *********************************** [Show More]

Last updated: 1 year ago

Preview 1 out of 16 pages