Answered step-by-stepChief Complaint/History of Present Illness: You have just completed..

Answered step-by-stepChief Complaint/History of Present Illness: You have just completed…Chief Complaint/History of Present Illness: You have just completed orientation to the ED in a suburban hospital that is designated Level III trauma center. It is your first position after passing your NCLEX. It has been a quiet night for a Saturday so far. The triage nurse suddenly brings back a 22 year old male to the stabilization (stab) room who is pale, diaphoretic, in obvious distress and having difficulty breathing. The w/c that he was brought back in is leaving a trail of blood behind it as well. His girlfriend is crying uncontrollably and states that they were one of the last customers to leave the local bar when they were confronted by two men who robbed her boyfriend and when he resisted she saw a knife and saw him stabbed at least once. The men fled and she was able to get him to the car where she drove to the ED.  Past Medical History: Unknown Nursing Interventions (primary survey A/B/Cs): Cut off all clothing to expose entire body and initiate primary/secondary survey to determine location of all trauma related to assaultA/B: apply O2 via non rebreather (NRB) at 15 litersA: apply c-collarC: Establish 2 large bore IVs (18 g) and then administer 1000 mL of 0.9% NS as fast as possible Your Initial Nursing Assessment (secondary survey): GENERAL APPEARANCE: anxious, in obvious pain moaning loudly and crying out, am I going to live? Is lying on his back and an evolving pool of blood is apparent from underneath each side of his chest as he lies on his back. You roll him on his side and notice a single 5 cm gaping stab wound in the right upper back that is oozing large amounts of blood. In addition to the bleeding you note that there are bubbles of blood present at the stab wound as well. RESP: breath sounds clear with good aeration on the left side, significantly diminished on the right side. Intercostal retractions noted with each heaving resp. effort that is tachypneic. Trachea is midline. CARDIAC: Pale, diaphoretic. Pulses palpable but faint in both UE/LE NEURO: Anxious, able to follow simple commands GI/GU: active BS in all quads, abd. soft/non-tender  Your Initial VS:                                 T: 98.5 (o)                                                                                P: 148 reg R: 36 labored/reg BP: 102/78 O2 sats: 86% RA…95% on 15 liters NRB  Physician Orders: Stat CXRPrepare for chest tube insertionInitiate second liter of 0.9% NS in second large bore IVType and cross for 4 units of PRBC’s Obtain 2 units of O neg PRBC from blood bank stat Stat CBC CBC  Current WBC (4.5-11.0)  8.8 HGB (12-16)  10.2 PLTS (140-440)  280 Neuts. % (42-72)  65  Lab/diagnostic Results: CXR: Absence of vascular markings noted on right side/lung collapse consistent with pneumothorax. No tension pneumothorax present at this time. What data from the chief complaint, VS &  nursing assessment is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT data: Chief complaint:           VS/assessment:                  Rationale: Chief complaint:           VS/assessment:    What lab/diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Diagnostic results:              Rationale:   What are the TWO primary problems that your patient is most likely presenting with? 1.  2.   What is the underlying cause /pathophysiology for each of these priority problems? 1.           2.          What nursing priority will guide your plan of care for each of these priority problems? 1.  2.    6. What interventions will you initiate based on the FIRST priority? Nursing Interventions: 1.  2.  3.  4.    Rationale: 1.  2.  3.  4.    Expected Outcome: 1.  2.  3.  4.    6. What interventions will you initiate based on the SECOND priority? Nursing Interventions: 1.  2.  3.  4.    Rationale: 1.  2.  3.  4.    Expected Outcome: 1.  2.  3.  4.    What is the relationship between the following physician orders and your patients primary medical problem?  MD orders: Stat CXR    Prepare for chest tube insertion   Initiate second liter of 0.9% NS in second large bore IV   Type and cross for 4 units of PRBC’s   Obtain 2 units of O neg PRBC from blood bank stat   Stat CBC    Rationale:  Expected Outcome:    What body system(s) will you most thoroughly assess based on the patient’s chief complaint and primary/priority concern?     What is the worst possible complication to anticipate? (start with A-B-C priorities)    What nursing assessment(s) will you need to initiate to identify and respond to quickly if this complication develops?      Caring & the Art of Nursing What is the patient likely experiencing/feeling right now in this situation?      What can you do to engage yourself with this patient’s experience, and show that they matter to you as a person? Health ScienceScienceNursingNURSING NSG221Share

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