Fluid Overload NextGen SKINNY Reasoning

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Present Problem: You are the nurse caring for Anthony Robinson, a 67-year-old African American male patient with a history of heart failure and iron deficiency anemia who was admitted to the medical... floor from the emergency department earlier this morning for low hemoglobin. Mr. Robinson’s initial hemoglobin was 6.2 and the primary care provider ordered 2 units of packed red blood cells (PRBC). He received the first unit in the emergency department (ED) over 90 minutes and tolerated well with no change in status. The second unit was started after he arrived on the floor and is nearly 2/3 finished. You are rounding on your other patients when Mr. Robinson presses his call light and states “I feel like I can’t catch my breath.” When you enter the room, you see Mr. Robinson in bed breathing rapidly and he appears anxious. 2. What VS data is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 What data from the additional information is RELEVANT and must be NOTICED as clinically significant by the nurse? 4. Interpreting clinical data collected, what problems are possible? Which problem is priority? Why? 5. What nursing priority will guide how the nurse RESPONDS to formulate a plan of care? 6. After implementing the plan of care, EVALUATE your patient by INTERPRETING relevant clinical data to determine if patient status is improving, declining, or reflects no change. [Show More]

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