A.

Emergency Room

1. A 26 year-old woman is brought to the emergency department after fainting while visiting her
mother in ICU. There is no seizure activity or head trauma. In triage, her finger stick glucose is 76 mg/dL
and partial pressure of oxygen is 99% room air. The patient denies drug and alcohol use, pregnancy, or
other medical conditions. Which information is now a priority for the triage nurse to obtain?

Since it is in an Emergency Setting, it is an utmost importance to perform an ABCDE assessment.

So as soon as the patient enters, we must check the patient’s airway, if there are any obstructions or if
the patient is breathing. Next would be to assess the patients breathing, check the patient’s respiratory
rate, chest movements, and oxygen levels with a pulse oximeter. The third one is to check the patients
Circulation, such as the capillary refill time, pulse/cardiac rate, and the blood pressure. Next would be,
Disability, the level of consciousness of the patients if she is alert or responsive. And lastly, Exposure,
checking from head to toe for any physical abnormalities that may affect her.

When the patient arrives at the Emergency Room she has a partial pressure of oxygen of 99%

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and since there was no mentioned equipment to help her breath, it means she is self-ventilated,

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whereas Airway and breathing are no longer a priority for her. Next would be circulation, blood pressure

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should be immediately taken since the patient fainted, which may have been caused by anxiety when

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she visited her mother in the ICU, she may have hyperventilated which could cause her to faint and

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lower her blood pressure, so this would be the utmost priority for the triage nurse to obtain. After that
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the nurse should check and assess the disability, since she fainted, she may have fallen, so we should
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check the patients level of consciousness. Then lastly, Exposure, the nurse should ensure that there were
no injuries from head to toe.
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2. A 70 year-old woman has a known history of Alzheimer's disease, hypertension, and diabetes.
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She is brought to the emergency department by her son because of new, nonstop verbal rambling and
pacing today. What is the best response for the triage nurse to do next?

Whenever a new patient enters the emergency room we should thoroughly assess the patient,
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using the ABCDE assessment. So first of all, airway and breathing. Since she has nonstop verbal rambling,
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it means that there is no problem with her airway and breathing. Then for Circulation, due to her non-
stop verbal rambling and pacing, it might cause her to increase her blood pressure, so the best response
would be to immediately take her blood pressure, and if the blood pressure is too high then you can ask
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the attending physician for medication for hypertension, to help lower her blood pressure. So if the
patient has a history of Alzheimer’s disease. Hypertension and diabetes may be contributing factors,
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because high blood pressure and diabetes can increase the risk of atherosclerosis and so will affect the
delivery of oxygen to the brain in which can cause an imbalance and flare up the patient’s Alzheimer’s
disease. When a patient has Alzheimer’s disease they can either be hypo-active or hyper-active, which
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can be the cause of the patient’s non-stop rambling and pacing. So that would be the utmost response to
check the patients’ blood pressure and check the blood sugar of the patient.

Right after that, assess the patients’ disability, which is where you check the patient’s blood
glucose, and since the patient has non-stop rambling it would immediately ensure a high glucose count,
because it may not be low glucose since she is not quiet. Then lastly, exposure, since she is a 70 year old

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 woman with a history of Alzheimer’s, we should check for anything that could increase her discomfort,
there may be feces in her underwear which could cause her to be pacing and non-stop rambling, or even
contusion that may be present which could cause her pain.

B. Medical Ward

3. O.H, a 56 year old female, has peripheral IV in her cephalic vein mid right forearm. It is a 20-
gauge, 1 inch catheter. Her infusion is dextrose 5% with 0.45 normal saline with 20 mEq of potassium
chloride per liter at 125 ml/hr. The nurse assesses the IV site.

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Risk for After a Monitor for These are the After a series
"Minsan infection series of redness, swelling, classic signs of nursing

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nararamdaman related to nursing increased pain, of infections. intervention

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kong compromised intervention purulent Any the patient

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sumasakit at circulation the patient discharge, and exit suspicious was able to

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namumula secondary to will remain sites of tubes (IV drainage remain free
yung peripheral free of tubings). should be of infection,

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pinagswerohan vascular
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sakin." damage evidenced antibiotic by normal
by normal therapy is vital signs
Objective: vital signs determined and absence
-Swelling on and absence by pathogens of signs and
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iv site of signs and identified. symptoms of

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-Rubor symptoms of infection.

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-Lack of infection. Temperature

hygiene Monitor for of greater
-temp of elevated that 37.7’C
37.6’C temperature may indicate
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infection,
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very high
temperature
accompanied
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by sweating
and chills
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may indicate
septicemia.

Aseptic
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Maintain or teach technique

asepsis for decreases the
dressing changes changes of
and wound care, transmitting
peripheral IV and or spreading
central venous pathogens to

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 management. the patient.
Interrupting
the
transmission
of infection
along the
chain of
infection is an
effective way
to prevent
infection.

Washing
Wash hands before before
handling the IV handling
catheter equipment

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will reduce

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the

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transmission

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of pathogens.

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ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
Subjective: Risk for After a series Instruct patient to IV catheter After a series
"hindi ko impaired skin of nursing reduce movement located on of nursing
maiwasang integrity intervention of the IV the vein areas intervention
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hindi magalaw related to the patient where flexion the patient

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ang aking fluid will be able occurs can was be able to

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braso tuwing infiltration to cause demonstrate

gagalaw" secondary to demonstrate dislodgement behaviors or
vesicant drug behaviors or of the techniques to
solution techniques to catheter promote
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promote healing and to

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Objective: healing and Educate patient This prevent

-Pt appears to prevent and caregiver information complications
uncomfortable complications about the cause of can assist the
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-+ Scratching/ pressure patient of the

itching on IV caregiver in
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site finding
- iv site is methods to
warm to touch prevent skin
- redness breakdown
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around IV site
Educate patient Skin integrity
and caregiver enhances
about proper skin their sense of
care self-efficacy
and prevents

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 skin
breakdown

Regular flow rate Rapid flow

according to the rate could
doctors order contribute in
developing
reactions
such as
extravasation

Check IV site every Patient could

2 hours, note for develop
signs of swelling, extravasation
redness, and pain due to the
drug being

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given also IV

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site is placed

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where flexion

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occurs

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C. Surgical OPD

C.P is in the recovery room after outpatient surgery. She received a general anesthetic and is
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now awake, breathing deeply and talking to the staff. She has received morphine sulfate intravenously
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and is quite comfortable. Before being discharged home from the surgery center, C.P rests in an easy
chair in the transitional recovery area. The nurse taking of her notices that she asks questions about
things that have already been discussed and even asked one question three times.
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1. After making these observations, what nursing diagnoses and goals might the nurse identify
for C.P?

2. List nursing interventions in caring for CP.

3. Identify teaching approaches.

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 D. Surgical Ward

G.S, a 74 year old retired school teacher who is married and the father of 4 and the grandfather
of 16, weighs 275 lbs. He has undergone a right hemicolectomy, wherein the right side of his colon was
removed because of cancer. Ha has a history of smoking but has no other health problems. The surgery
was uncomplicated, and he is in the PACU. He has a midline incision with a Penrose drain and a stab
wound with a Jackson-Pratt drain adjacent to the incision. He has also NGT attached to low intermittent
suction. He is alert and oriented and moves all four extremities freely. His blood pressure is normal for
him in comparison to his perioperative levels. He is breathing regularly and easily at a rate of 16 breaths
per minute, and his skin color is pink. His oxygen saturation, however, is 86% with additional oxygen
given via mask.

1. .What risk factors for developing postoperative complications can you identify for GS?

Since the patient G.S is undergoing a hemicolectomy, there are risks and complications

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like, excessive bleeding. Internal injury may occur, because during the procedure, there may be
damage to the bladder or surrounding organs. Anastomotic leak, anastomosis is the site where

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the colon reattaches, and the colon can leak at the point of the anastomosis. Infection, infections
can occur on any surgery, so to prevent this antibiotics may be needed. And lastly, Colostomy,

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when reattachment is not possible, the surgeon may need to do a colostomy, and will attach a
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colostomy bag to the stoma to collect the body’s waste.

2. What nursing measures can you institute to promote oxygenation?

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The patient is on 86% oxygen saturation, with additional oxygen via mask, in order to
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promote proper oxygenation, we must raise the head of the bed, raising the head of the bed
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promotes effective breathing and maximizes inhalation, which decreases the work of breathing.
Deep breathing and coughing techniques, this helps the patient clear their airway. And lastly
would be to assess the need for bronchodilators, bronchodilators relaxes muscles and open
airways.
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3. What nursing observations can be made and reported to indicate to the surgeon that the NGT
can be removed?
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The Nasogastric Tube can be removed once the patient is able to defecate properly,
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passing flatulence and absorb the food he is taking without vomiting, but if the patient has a
colostomy, we should ensure that the colon is active and also able to release feces. And the
Nasogastric tube can only be removed once there are no more complications present or there
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are no occurrences of any complication.

4. What nursing measures can be implemented to prevent deep vein thrombosis,

thrombophlebitis and pulmonary embolism?

Nursing measures to prevent deep vein thrombosis are, to lose weight, stay active, and
exercise regularly, this is to prevent formation of blood clots which could cause deep vein

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 thrombosis. To prevent thrombophlebitis you must avoid long periods of standing and, if
possible, we must elevate the leg when sitting. Regular exercise is also applicable, especially
walking moderately. And if the patient is pregnant or have varicose veins, they can wear support
stockings to relive a low blood flow. In order to prevent pulmonary embolism, exercising
regularly is important, drinking plenty of fluids like water and juice but avoiding alcohol and
caffeine, do not smoke and lose weight if you are overweight, and try to elevate your legs for at
least 30 minutes twice a day to promote proper flow of blood.

5. Write and prioritize three individualized nursing diagnoses and outcomes for GS.

a. Acute pain

May be related to: Physical factors, (incision/drains)

Biological factors, (cancer)

Possibly evidenced by: Autonomic response, (low level of oxygen saturation)

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Desired outcomes: Client will verbalize that paint is relieved/controlled

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Client will display relief of pain, able to sleep/rest

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b. Risk for Deficient Fluid Volume

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Risk Factors: Excessive losses through abnormal routes, (NGT)
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Excessive losses through normal routes, (Diarrhea)

Desired outcomes: Client will be able to maintain adequate hydration

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c. Impaired Skin Integrity

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May be related to: Stasis of secretion/drainage

Possibly evidenced by: Disruption of skin/tissue (incision, sutures and drains)

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Desired outcomes: Client will achieve timely wound healing free of signs of
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infection

6. What information will GS need before discharge?

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Since the removal of colon was because of cancer, chemotherapy may also be necessary
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as an additional treatment. The patient may experience diarrhea or loose stools, which will be
common especially after his surgery, which can last from weeks to months, but if you have a
bloody diarrhea, you must contact your surgeon immediately, because this may be a sign of
bowel infection. Diet must be properly followed as prescribed by the hospital, most likely you
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may be on a low fiber diet, fiber can help with the diarrhea, but if a certain food occurs to a
stomach ache, you must avoid it for a while. Medications must be taken strictly as directed, do
not skip doses. Drink at least 8 glasses of water every day to prevent dehydration especially if
you have an colostomy bag or you are experiencing diarrhea.

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