NURS 231 - Nursing Process VI: Medical-Surgical Nursing IV Clinical Reasoning Table.

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Carrington College – NURS 231 Nursing Process VI: Medical-Surgical Nursing IV Clinical Reasoning Table – submitted CRT must be in a Word document in the correct format Student Name: Kendall Harr... ison Clinical Reasoning Table (indicate which one) 1 – 2 – 3 – 4 Brief Patient Background of Current Admission (e.g. events leading to admission and admitting diagnosis, current state of patient condition): Patient was involved in skiing accident on 1/22. Was resuscitated while en route to Renown hospital. Patient presented to the hospital with may injuries: Respiratory failure from trauma, traumatic hemothorax, acute blood loss anemia, contusion of both lungs, closed fracture of multiple ribs on right and left side, pneumomediastinum, spleen laceration, bi-lateral lung laceration, multifracture of thoracic spine. Patient is stable during initial assessment, sedated, responds to stimuli and follows commands as given. However, patients condition changes rapidly following the doctors’ orders to remove the mechanical ventilation. Patient becomes unstable. Unable to maintain oxygen saturation and O2 saturation drops rapidly, within minutes O2 sat drops to 68% and patient is fitted with high flow nasal cannula delivering 40L/min. Code Status: FULL Allergies: NONE Past Medical/Surgical History: NONE Head-to-Toe Assessment (your shift assessment; do not include historical or admission data) Top 2 Problem Statement(s) using the syntax of Basic Human Need R/T …… aeb …… Include the “aeb” for At Risk Problems as well Goals Must be congruent with the problem and measurable. One goal per problem. Nursing Actions What did you actually do to help the patient meet the goal? Be specific about any medications you gave, i.e. med, dose, route Evaluation/Reformulation Did the patient meet the goal – Yes or No. Why yes or why no? Could something different have been implemented? Was the goal realistic? Vital Signs (T, P, R, BP, O2 Sat, include oxygen amount) 0800: T 98.1 P 91 R 15 BP 126/80 O2 Sat 98 on 30%O2 1200 (ICU/CIC only): T 100.1 Problem Statement #1: Ineffective breathing pattern related to decreased lung expansion caused by multipole broken ribs, and blood entering the lung cavity also decreasing the lungs ability to expand and fill with air spontaneously. As evidenced by deteriorating O2 saturation, short-rapid breathing pattern, abnormal arterial Goal #1: Maintains breathing pattern to retain ABG’s within normal parameters Goal #2: Decrease in self-reported pain, decrease in pain related behaviors, return to baseline b/p, RR, pulse, temperature. Interventions for Goal #1: 1. HOB to 60 degrees to maximize diaphragmatic breathing and vital capacity. 2. Coached patient to breathe deeply and remain awake with eyes open to focus on breath rate and depth. 3. Suctioned airway and encourage patient to cough. Evaluation/Reformulation for Goal #1: 1. Goal not met. After implementing the interventions, patient became stable. ABG’s did not return to normal with a change in CO2 going from 80 to 50. Breathing pattern was still shallow, but O2 saturation returned to baseline, B/P, RR, Pulse and Temp also returned to normal parameters. [Show More]

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