This week’s graded discussion topic relates to the following Course Outcomes (COs).
- CO1 Utilize prior knowledge of theories and principles of nursing and related disciplines to explain expected client behaviors, while differentiating between normal findings, variations, and abnormalities. (PO 1)
- CO2 Recognize the influence that developmental stages have on physical, psychosocial, cultural, and spiritual functioning. (PO 1)
- CO3 Utilize effective communication when performing a health assessment. (PO 3)
- CO5 Explore the professional responsibilities involved in conducting a comprehensive health assessment and provide appropriate documentation. (PO 6)
Please choose one of the patient scenarios below. Next, complete a rapid assessment, and provide a SBAR report to a classmate. Remember to include all concepts of patient safety, standard precautions, and professional standards.
- You are covering for a coworker who is off the floor for lunch, when you suddenly hear a loud crash coming from a nearby patient room. You quickly run in and discover Mr. Johnson who was admitted yesterday with a diagnosis of cerebral vascular accident (CVA) unconscious on the floor between the bed and the bathroom.
- You are called to the room of 2-year-old Jonah by his mother who states the child has suddenly started breathing very loudly and does not look right. Upon entering the room, you quickly recognize that the child is in respiratory distress as his lips are cyanotic and the use of accessory muscles is evident.
- You are in the process of admitting Ashley, a 27year old who is 28 weeks pregnant with her first child, to the obstetric unit for complaints of headache, dizziness, and swelling of her lower extremities when she suddenly begins seizing.
Hello Professor and classmates,
Let’s take a look at scenario 1) you are covering for a coworker who is off the floor for lunch, when you suddenly hear a loud crash coming from a nearby patient room. You quickly run in and discover Mr. Johnson who was admitted yesterday with a diagnosis of cerebral vascular accident (CVA) unconscious on the floor between the bed and the bathroom.
Upon entering the room I would be looking around is there blood? Any obvious signs of injury? Did he trip over something? As I approached the patient I would be assessing for: General appearance: The patient is unconscious. Is he responding to his name? Does his eyes open spontaneously? Is he answering? If he is, is his speech clear, is he making sense? Physical assessment: Does he have a pulse? Is he breathing? Is he moving? Both sides equally? (JARVIS, 2016, pp. 799-800) I would obtain vital signs if he has a pulse and respirations. I would get a blood sugar. I would be protecting his neck and head for any possible injuries. There is very little information known, did the patient have TPA, should we be concerned for a hemorrhagic stroke, is he throwing clots from an abnormal heart rhythm. “Hemorrhagic transformation (HT), which refers to a spectrum of ischemia-related brain hemorrhage, is a frequent spontaneous complication of ischemic stroke, especially after thrombolytic therapy” (Zhang, 2014 ).
Situation. My name is Christine I am calling from CCU about Mr. Johnson in room CCU5 who was found unconscious on the floor in his room.
Background Mr. Johnson was admitted yesterday for a CVA, current vital signs are __? Blood Glucose is__? It is not quite clear what caused the fall.
Assessment. Mr. Johnson is currently unresponsive, I am not sure if this is related to his stroke
Recommendation I would like to get CAT scan of the head and neck to rule out intracranial bleed, Progression of the stroke or injury to the cervical spine.