Promoting an inter-professional environment. The nurse practitioner is employed in a newly created attending role on an inpatient unit. To promote an inter-professional environment. The nurse practitioner:

A. assign  a role for all staff members in improving patient outcomes.

B. Discusses the resistance directly with physicians

C. Educates staff members on the role of  a the nurse practitioner.

D. Instructs staff nurses on scope of practice.

 

SKINNY Reasoning
Part I: Recognizing RELEVANT Clinical Data
History of Present Problem:
Jared Johnson is a 10 year-old African-American boy with a history of moderate persistent asthma. He is being admitted to the pediatric unit of the hospital from the walk-in clinic with an acute asthma exacerbation. Jared started complaining of increased chest tightness and shortness of breath one day prior to admission. He has been at 50 percent of his personal best measurement for his peak expiratory flow (PEF) meter reading which did not improve with the use of albuterol metered dose inhaler (MDI) (per his written asthma management plan).
In the walk-in clinic Jared is alert, speaking in short sentences due to breathlessness at rest. He has coarse expiratory wheezes throughout both lung fields with decreased breath sounds at the right base. His oxygen saturation on room air is 90%. His color is ashen and he has dark circles under his eyes. He is sitting upright and using his accessory chest muscles to breath and has moderate intercostal and substernal retractions. He is complaining of tightness in his chest. Jared was diagnosed with asthma at age 6 years and has three prior hospitalizations for asthma with one admission to the pediatric intensive care unit. He has never had to be intubated with these episodes.
Personal/Social History:
He is accompanied by his mother and 16-year-old sister. Jared lives with his mother, maternal grandmother, and sister in an older housing development in the inner city. He is in the 5th grade and a good student despite two to three absences per school year for his asthma. He likes to ride his bike and is the goalie on the soccer team. He says that he has lots of friends at school and likes his teacher, Mr. Bates, who is also his soccer coach. Both Jared and his mother deny tobacco smoke at home.
What data from the histories are important and RELEVANT; therefore it has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: RELEVANT Data from Social History: Clinical Significance:
Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 99.9 F/37.7 C (oral)
Provoking/Palliative:
Worsens when tries to take a deep breath. Feels better when allowed to sit upright on gurney
P: 120 (regular)
Quality:
Tightness
R: 30 (regular)
Region/Radiation:
Across anterior chest
BP: 114/78
Severity:
8/10
O2 sat:
90% on room air
Timing:
Constant
End Tidal CO2: 30
© 2018 Keith Rischer/www.KeithRN.com
What VS data are RELEVANT and must be recognized as clinically significant to the nurse? RELEVANT VS Data: Clinical Significance:
What assessment data are RELEVANT and must be recognized as clinically significant to the nurse? RELEVANT Assessment Data: Clinical Significance:
Diagnostic Results: Basic Metabolic Panel (BMP) Na K Gluc. Creat.
Current:
138
3.7
80
0.6 Complete Blood Count (CBC) WBC % Neuts HGB PLTs
Current:
10.0
55
14.1
350
Radiology:
Chest x-ray
Hyper-expansion of airways with otherwise clear lung fields.
What data must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Diagnostic Data: Clinical Significance: Current Assessment:
GENERAL APPEARANCE:
Ashen, anxious appearing, moderate respiratory distress. Sitting upright on gurney. Only able to talk in short sentences due to breathlessness. Has intercostal and sub-sternal retractions with increased respiratory rate, using accessory muscles to breathe (sternocleidomastoid muscles).
RESP:
Breath sounds with inspiratory and expiratory wheezing and prolonged expiration. Has tight-sounding non-productive cough, decreased breath sounds in right base
CARDIAC:
Pale, warm & moist at forehead, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks
NEURO:
Alert & oriented to person, place, time, and situation (x4)
GI:
Abdomen soft/non-tender, bowel sounds audible per auscultation in all four quadrants
GU:
Voiding without difficulty, urine clear/yellow
SKIN:
Skin integrity intact, moist on forehead
© 2018 Keith Rischer/www.KeithRN.com
Part II: Put it All Together to THINK Like a Nurse!
1. After interpreting relevant clinical data, what is the primary problem?
(Management of Care/Physiologic Adaptation) Problem: Pathophysiology in OWN Words:
Collaborative Care: Medical Management
2. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies) Medical Management: Rationale: Expected Outcome:
Vital signs every 1 hour and as needed
Continuous oxygen saturation monitoring
Continuous end tidal CO2 monitoring
Start peripheral IV then saline lock
O2 to keep saturations >93%
Albuterol 2.5 mg and ipratropium bromide 0.25 mg via face mask nebulizer every 20 minutes as needed for respiratory distress
Methylprednisolone IV loading dose 2mg/kg then start Methylprednisolone IV 0.5 mg/kg every 6 hours for 48 hours
Diet as tolerated
© 2018 Keith Rischer/www.KeithRN.com
Collaborative Care: Nursing
3. What nursing priority (ies) will guide your plan of care? (Management of Care) Nursing PRIORITY: PRIORITY Nursing Interventions: Rationale: Expected Outcome:
4. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity) Psychosocial PRIORITIES: PRIORITY Nursing Interventions: Rationale: Expected Outcome:
CARING/COMFORT:
How can you engage and show that this pt. matters to you?
Physical comfort measures:
EMOTIONAL SUPPORT:
Principles to develop a therapeutic relationship
SPIRITUAL CARE/SUPPORT:
5. What educational/discharge priorities need to be addressed to promote health and wellness for this patient and/or family? (Health Promotion and Maintenance)