King

Saud bin Abdul-Aziz University for Health Sciences

College of Nursing – Jeddah

Fundamentals of Nursing II – NURS 202

Spring 2020

Clinical reasoning assignment

34

Submitted by: Lama Submitted to: Dr. Seham gamal

Student`s Name: Lama alshehri

Student’s ID: 391220621

Course Name and Code: NURS 202

Section: C

Date: 18-4-2020

Spring 2020

King Saud bin Abdul-Aziz University for Health Sciences

College of Nursing – Jeddah

Fundamentals of Nursing II – NURS 202

Spring 2020

Clinical reasoning assignment

Case scenario:

Mr. Ahmed is a 59 years of age male patient who is admitted to the medical unit with acute

community acquired pneumonia.

The patient smoked cigarettes one pack per day for 30 years and quit 3 years ago. He has a

history of hypertension, asthma, and diabetes controlled oral diabetic agents.

The patient presents with confusion as to time and place. The family stated that this is a new
change of the patient. The admission vital signs are as follows: Bp 90/50 mmHg, HR 105 bpm,

RR 28 breaths/min, and temperature 38.6 C.

The patient complains of fatigue and shortness of breath and cannot finish a short sentence

before the respiratory rate increases above the baseline and nail bed and lips turn a bluish in

color and Oxygen saturation decreases to 88%. The patient is diaphoretic and is using accessory

muscles. He coughs weakly with minimal amount of thick sputum.

Based on the scenario above, answer the following questions:

1. Interpret the patient vital signs and state the normal ranges for each one of them?

(5 marks)

Patient’s reading Interpretation Normal range

(Write medical terminology of the (write it with unit of

patient finding) measurement)

Blood pressure 90/ 50 mmHg Hypotension 120/80 mmHg

Pulse 105 bpm Tachycardia 60-100 bpm

Respiratory Adult: 14-20b/m

rate 28 b/m Tachypnea Infant: 30-50b/m

Temperature 36 C and 37.5 C

38.6 C Pyrexia (96.8 F to 99.5 F)

O2 Saturation 88% 95-100%

Hypoxemia

The physician ordered 5L of oxygen therapy to be administered for this patient and to put him on

antibiotic therapy of Ceftriaxone 1g intravenously q24h and Azithromycin 500mg orally q24h.

2. Which oxygen device will be used to administer the prescribed oxygen therapy?

How much oxygen concentration this device will deliver? (2 marks)

Simple face mask - 40% to 60%

…………………………………………………………………………………………..

King Saud bin Abdul-Aziz University for Health Sciences

College of Nursing – Jeddah

Fundamentals of Nursing II – NURS 202

Spring 2020

3. What is the reason for putting the patient on oxygen therapy? (1mark)

1-To relieve dyspnea

………………………………………………………………………………………………………

2-To administer specified amount of oxygen

………………………………………………………………………………………………………

4. Mention the steps of oxygen therapy administration. (5 marks)

1-First review doctor's order for ( type of device and oxygen concentration). 2- Greets patient and introduces self

3- Identifies the patient (name and ID) 4- prepare privacy and defines procedure 5-cleanse hand 6-assists
……………………………………………………………………………………………..………..
patient position (semi-fowlers) 7- assesses patient prior to administering oxygen (vital signs ,lab value , oxygen
……………………………………………………………………………………………..………..
saturation 8- For prepares required equipment face mask tools First adhere the flow meter to the oxygen source Then

……………………………………………………………………………………………..………..
Connect the humidifier with distilled water or tap water to the flow meter Then attach the delivery decive to humidifier 9- in face
mask the……………………………………………………………………………………………..………..
mask should apply from the nose downwards 9.2 fit the metal piece on the mask to fit the shape of the
patient's nose 9.3 secures the elastic band comfortably around the patient's head 10- start the oxygen ( checks the
……………………………………………………………………………………………..………..
oxygen flow by feeling the mask ) 12- ensure decent function of the system ( bubbling in the humidifier,
……………………………………………………………………………………………..………..
kniks in tubing , maintain tube dry ) 13- ensure the patient frequently ( flow rate , water level , skin irritation, o2
saturation ……………………………………………………………………………………………..………..
14- provides patient safety (reposition the patient, bed at the lowest poistion , sides rail up , call bell in
reachable place , bed breaks in lock positions 15- wash hand 16-documents appropriately (time ,flow rate ,o2
concentration
5. Calculate the antibiotics doses to be administered based on the stock dose shown in

the figures below? (6 marks; 3marks/ drug)

Drug name Used formula and steps Results Stock dose

Ceftriaxone

Volume(ml)

___________
Time (hr) 0.04 ml

______ =0.04ml
24

King Saud bin Abdul-Aziz University for Health Sciences

College of Nursing – Jeddah

Fundamentals of Nursing II – NURS 202

Spring 2020

Azithromycin

D *V

DM

500mg*1
= 2 tablets

250mg

6. List important considerations that you should perform before administering

intravenous medication? (3.5 marks)

1- Assess the vital signs.

……………………………………………………………………………………………..…..

2-. Assess the site for any phlebitis, infiltration and sclerosis.
……………………………………………………………………………………………..…..

3- Assess for bleeding tendencies.

4-Assess for allergies and contraindication

……………………………………………………………………………………………..…..

5- Dilute the drug as indicated by pharmacy

……………………………………………………………………………………………..…..

references.

……………………………………………………………………………………………..…..
6- Determine the correct rate of administration

7- if IV push is to be given with an ongoing IV infusion or to follow another IV

……………………………………………………………………………………………..…..

push medication, check pharmacy for possible incompatibility

……………………………………………………………………………………………..…..

7. What nursing diagnosis (2 actuals, 1 potential) should the nurse formulate for the
patient? (3 marks)

Actual ;

……………………………………………………………………………………………..…..

Ineffective breathing pattern releated to alteration of patients o2/co2 ratio as

……………………………………………………………………………………………..…..
evidenced by cough with sputum production

……………………………………………………………………………………………..…..

Impaird gas exchange related to altered delivery of oxygen evidence by shortness of breath

……………………………………………………………………………………………..…..

……………………………………………………………………………………………..…..

……………………………………………………………………………………………..…..
Potental ;

Risk for imbalanced nutrition ; less than requirment releated to fever and infection process

King Saud bin Abdul-Aziz University for Health Sciences

College of Nursing – Jeddah

Fundamentals of Nursing II – NURS 202

Spring 2020

Patient will be discharged home with MDI for his asthma and when you assessed his

knowledge in regard of MDI administration, the patient demonstrated in improper way.

8. Discuss the health education that should be provided for this patient on MDI
administration?
(5.5 marks)
1. Eliminates
……………………………………………………………………………………………..…..
the cap and keeps upside down the canister, 6 . Holds breathe for about 10 seconds (if possible).

shake the inhaler for 3 to 5 seconds

……………………………………………………………………………………………..…..
7. Remove the inhaler from the mouth and slowly
2. Connect MDI to spacer if needed
exhale through the lips of the tube.

……………………………………………………………………………………………..…..
3. Tilt the head slightly back and exhale
8. Repeat inhalation if ordered. Wait 20 to 30 seconds
4. Add the……………………………………………………………………………………………..…..
mouthpiece far enough into the mouth with its between inhalations.

opening towards the throat. Close the lip tightly around the 10. If two inhalers are to be used, the bronchodilator
mouthpiece.
……………………………………………………………………………………………..….. medicine (which expands the airways) should be given
5. Push the inhaler down to release the drug (one puff), before other medications, such as corticosteroid.

……………………………………………………………………………………………..…..
while gradually inhaling for 3-5 seconds.

9. Calculate the intake and output for this patient and indicate is the balance for 24
hours based on the following data: (3 marks)
Intake Output

IV Oral Urine Fecal

Morning shift: 750 ml 450 ml 1050 ml -

Night shift 600 ml 300 ml 900 ml 100 ml watery

Intake : 750ML + 450ML+600ML+300ML=2100ML

……………………………………………………………………………………………..…..

Output: 1050ML + 900ML+100NL=2050ML

……………………………………………………………………………………………..…..

Balance; 2100-2050 =50ML

……………………………………………………………………………………………..…..

……………………………………………………………………………………………..…..

……………………………………………………………………………………………..…..

……………………………………………………………………………………………..…..