CC Case Study NGN Fall 2022 (1)
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University of Wisconsin, Platteville *
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Industrial Engineering
Date
Dec 6, 2023
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Uploaded by BaronRoseGiraffe15
CHA 2 Fall, 2022
Critical Care Case Study
Name(s)______________________________________________________
The patient is a 53-year-old man who had an open reduction of his right
forearm after falling from a tree while trimming it. His only health problems
are mild hypertension and being 15 pounds underweight for his height. His
history includes that he smokes two packs of cigarettes and drinks a six-
pack of beer daily. When he comes to the day surgery recovery unit, his vital
signs are: BP, 142/90; pulse, 86; respirations, 18; pulse oximetry, 97%. The
dressing around his forearm is dry and intact. The fingers of his right hand
are warm and pink with good capillary refill. When you call his name, he
responds although he does not open his eyes.
Recognize cues:
What clinical data is significant to the nurse?
Data
(Recognizing cues)
It is now 15 minutes later, and the patient's BP is 140/92; pulse, 92;
respirations, 18. Pulse oximetry is 95%. The dressing is dry and intact, his
fingers are slightly cool, and capillary refill is slightly slower than during the
previous assessment. He is awake and tells you that his right arm hurts and
that he is thirsty.
Recognize cues:
What clinical data is significant to the nurse?
Data
(Recognizing
cues)
No-action/
Irrelevant
Improvement
Declining
CHA 2 Fall, 2022
Critical Care Case Study
In another 15 minutes his vital signs have changed: BP, 132/96; pulse, 100;
respirations, 22. He tells you that the pain is much better but that he is very
thirsty and feels light-headed and a little nauseated. He then belches twice.
His postoperative orders read that the IV can be removed when 1000 mL has
infused if he is stable.
Recognize cues:
What clinical data is significant to the nurse?
Data
(Recognizing
cues)
No-action/
Irrelevant
Improvement
Declining
Critical Thinking question:
Would you remove his IV at this time?
Why or why not?
Analyzing cues:
What cues are most concerning?
What does this data mean?
What is the TREND of relevant clinical data?
You retake his vital signs in 10 minutes: BP, 106/80; pulse, 112; respirations,
26. Pulse oximetry is 90%. Just as you start to check his capillary refill, he
says “Josey (his wife's name), bring me a bucket, I am going to be sick.” With
that he vomits a large amount of bright red blood.
Recognize cues:
What clinical data is significant to the nurse?
Data
(Recognizing
cues)
No-action/
Irrelevant
Improvement
Declining
CHA 2 Fall, 2022
Critical Care Case Study
Prioritize hypothesis:
What problems are possible based on the collected cues?
What problem is most important to manage first?
What COMPLICATION is the patient at greatest risk to develop?
Generate solutions:
What is the desired outcome?
What orders will be anticipated by the nurse?
Take action:
What intervention(s) is needed immediately?
Other:
Which vital sign changes are consistent with shock?
What type of shock is likely present?
What is the most likely cause of the bleeding?
Is there anything a nurse could have done differently to identify shock earlier?
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