12:45 pm…Katie, 18 years old/Camper #4 Primary Problem/Story: Katie is a grounds worker who walked down the ramp of the food truck with a box of food when her leg went through a hole on the ramp.

67 Preventing Infection Match the practices with the correct principles for surgical asepsis. A. A sterile item can only touch another sterile item.
November 13, 2019
28. Minor blows to the head never lead to long-term brain injury.
November 13, 2019

12:45 pm…Katie, 18 years old/Camper #4 Primary Problem/Story: Katie is a grounds worker who walked down the ramp of the food truck with a box of food when her leg went through a hole on the ramp.

12:45 pm…Katie, 18 years old/Camper #4 Primary Problem/Story: Katie is a grounds worker who walked down the ramp of the food truck with a box of food when her leg went through a hole on the ramp. She reports twisting her left hip with a sudden onset of pain What Do You Notice? Clinical Significance: Katie limped into the health center and told the nurse, “My left hip hurts. I can move it but it hurts a lot.” What Do You Notice? Clinical Significance: Past Medical History: Katie is a healthy 18-year old with no prior history of back or hip injuries Social History/Concerns: None to contribute to the current situation Vital Signs: T: Not taken What Do You Notice? Clinical Significance: What Do You Notice? Clinical Significance: P: 82 (reg) R: 22 (reg) BP: not taken 02 sat: not taken What Do You Notice? Clinical Significance: P-Q-R-S-T Pain Assessment: Provoking/Palliative: Onset with injury Quality: Constant Region/Radiation Left hip and leg Severity: 8/10 Constant and began with injury Timing: What Do You Notice? Clinical Significance: Initial Nursing Assessment: Patient unable to bear weight while walking on left leg. The range of motion of left hip decreased on left leg. The range of motion of left hip decreased What Do You Notice? Clinical Significance: Focused Nursing Assessment: GENERAL APPEARANCE: Limped to find a nurse in the dining hall RESP: Nonlabored resp, effort CARDIAC: Pedal and post-tibial pulses equal, 2+, lower extremities pink, warm NEURO: Alert and oriented. Moves all four extremities. Denies numbness, weakness, and tingling in lower extremities Copyright 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. 1. Identify the problem(s) impacting wellness in this setting. Interpreting relevant clinical data, what caused the problem? (Management of Care/Physiologic Adaptation) Problem: Cause/Pathophysiology: 2. What nursing priority (ies) will guide your plan of care? (Management of Care) Nursing PRIORITY: PRIORITY Nursing Interventions: Rationale: Expected Ou 3. What is the most likely complication(s) to anticipate based on the primary problem? What is the most important next step that the nurse needs to implement? (Reduction of Risk Potential/Physiologic Adaptation) Most Likely Complication: Nurses Next Step: Copyright 2019 Keith Rischer, d/bl/a KeithRN.com. All Rights reserved. 1:00 pm…Andy, 24 years old/Camper #5 Primary Problem/Story: You are leaving the dining hall when you hear one of the kitchen workers call out What Do You Notice? Clinical Significance: “Nurse, nurse, a guy passed out in the kitchen!” Patient status: His respirations are rapid and labored. His hands are numb, and he is now awake but lethargic. Subjective Data: The patient can barely speak or follow commands due to his compromised state. He was observed “fainting” by others Past Medical History: Andy is 24 years old and a kitchen worker No health history is available Social History/Concerns: None available Vital Signs: T. 99 2 F/37 3 C (oral) What Do You Notice? Clinical Significance: What Do You Notice? Clinical Significance: What Do You Notice? Clinical Significance: Vital Signs: T: 99.2 F/37.3 C (oral) What Do You Notice? Clinical Significance: P: 122 (reg) R: 34 (reg) BP: 88/46 02 sat: 97% room air What Do You Notice? Clinical Significance: P-Q-R-S-T Pain Assessment: Provoking/Palliative: Denies pain Quality: Region/Radiation: Severity: Timing: Focused Nursing Assessment: Andy is confused but able to follow commands when the nurse arrives. He is What Do You Notice? Clinical Significance: sweating profusely and complains of generalized muscle cramps Copyright 2019 Keith Rischer, d/bla Keith RN.com. All Rights reserved. What Do You Notice? Clinical Significance: Complete Nursing Assessment: on left leg. The range of motion of left hip decreased What Do You Notice? Clinical Significance: Focused Nursing Assessment: GENERAL APPEARANCE: Limped to find a nurse in the dining hall RESP: Nonlabored resp, effort CARDIAC: Pedal and post-tibial pulses equal, 2+, lower extremities pink, warm NEURO: Alert and oriented. Moves all four extremities. Denies numbness, weakness, and tingling in lower extremities Copyright 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved. 1. Identify the problem(s) impacting wellness in this setting. Interpreting relevant clinical data, what caused the problem? (Management of Care/Physiologic Adaptation) Problem: Cause/Pathophysiology: 2. What nursing priority (ies) will guide your plan of care? (Management of Care) Nursing PRIORITY: PRIORITY Nursing Interventions: Rationale: Expected Ou 3. What is the most likely complication(s) to anticipate based on the primary problem? What is the most important next step that the nurse needs to implement? (Reduction of Risk Potential/Physiologic Adaptation) Most Likely Complication: Nurses Next Step Copyright 2019 Keith Rischer, d/bla Keith RN.com. All Rights reserved. Put it All Together: Think Like a Community Health Nurse! 1. Ifall five patients presented at the same time, who would you assess first? Why? What health concerns are present with this camp community? 2. Immediate safety concerns: a. b. Camp manager issues: Safety committee: C. d. Camp community culture changes: Safety committee: c. d. Camp community culture changes: State reportable injuries: e. f. Communication 3. What are the nursing interventions for the campers, staff, and the camp community at the primary, secondary and tertiary level of care? (Nursing roles to consider are the following: educate, advocate, manage, collaborate, leadership) Primary Prevention Level: Keep disease or injury from occurring. (Educate) Secondary Prevention Level: Detect and treat existing disease or injuries. (Screen and treat) Tertiary Prevention Level: Reduce the disease or injury to the lowest level to minimize disability (Rehabilitation) High Incidence Problems in Camp Population: What problems are most frequently seen in a camp population?

 

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