XAVIER UNIVERSITY - ATENEO DE CAGAYAN

COLLEGE OF NURSING
S.Y. 2016-2017

CASE STUDY FOR PATIENT ADMISSION

Submitted by:

Diane Marie R. Estandarte

Level IV Student Nurse

Submitted to:

Mrs. Leny Baguio, RN, MN

Mr. Philip Eli Nalzaro, RN, MN

Mrs. Mary Grace Paayas, RN, MAN

Mrs. Rhenzi Pepito, RN, MN

Mrs. Mildred Pinque, RN, MN

BSN IV NA

June 24, 2017

CASE STUDY (Trueman, M.S. 2014)

After 6 weeks in the nursing arts lab learning basic skills of nursing

assessment, SN Malinda Upchurch is assigned to a medical-surgical nursing unit.

Her first day there is to help her acclimate to the unit. She is asked to take the vital

signs on the six patients, ranging in age from 51 to 89, assigned to her.

1. What are the expected values of temperature, pulse rate, respirations, and

blood pressure for these patients?

Consider each of the following situations as SN Malinda completes her rounds

on these patients.

Mrs. Rojas, 84 years old, does not understand English, with new onset

hypertension

Mr. Oxendine, 51 years old, on oxygen therapy with a partial rebreather mask

for hypoxia breathing rapidly through his mouth

Mr. Hines, 77 years old, with congestive heart failure, requiring multiple

cardiac medications

Mrs. Tescarelli, 72 years old, being evaluated for episodes of syncope

Mr. Leuong, 89 years old, confused, with fever from an acute urinary tract

infection
REACTION

As a student nurse, we are expected to know the base normal values for the

vital signs of the different age groups. Complete vital signs taking should include the

five aspects of the Pulse Rate, Respiratory Rate, Blood Pressure, Temperature, and

Pain. Given by the case study, the nurse was ordered to take the vital signs of 2

patients with an age range of 50 80 years old. The normal vital signs values will be:

Pulse Rate: 60-100 bpm

Respiratory Rate: 12-20 bpm

Blood Pressure: 90/60 mm/Hg to 120/80 mm/Hg

Temperature: 36.5 C - 37.5 C (97.8F - 99.1F)

Pain: 0 out of 10

However, with the increased age of the patients, there will be some age

related changes such as an increase gap between the systolic and diastolic blood

pressures due to arterial wall stiffness leading to an increase workload of the heart or

the increased respiratory rate due to the decline in elastic recoil, coupled with the

decline in chest wall compliance. The nurse must also take in mind that each

individual health is different therefore the baseline datum may vary from each

patient. In addition, if needed or as ordered, the nurse must also check the other

proposed vital signs of mental status, and oxygen saturation.

With the cases provided, the most likely abnormal values for each patient

would be:

Mr. Oxendine: Increased RR of more than 20 bpm.

Mr. Hines: Increased and irregular PR of more than 100 bpm,

 Aside from taking the vital signs of each patient, the nurse must also conduct

the other basic nursing assessment and responsibilities of regulating the intravenous

rate in accordance to the ordered flow rate, check the input and output for any

abnormalities, comfort of the patient in the hospital from admission to the present

time, and to build rapport with the patient themselves and their significant other(s).

With every procedure done by the nurse, she must make sure to introduce herself

initially, explain the procedure thoroughly making sure the patient understood, and

obtain consent before conducting.

After conducting the nurses rounds, the nurse must document all the findings

of both normal and abnormal. When needing to relay the abnormal findings to the

admitting physician, she must follow the chain of command.

Next step would be to prioritize the list of patients according to who needs

immediate care or close supervision to the least life threatening condition without any

prejudice. It is important to treat all patients equally and respectfully. Prioritization of

patients would be:

1. Mr. Oxendine, 51 years old, on oxygen therapy with a partial rebreather mask
for hypoxia breathing rapidly through his mouth

2. Mr. Hines, 77 years old, with congestive heart failure, requiring multiple
cardiac medications

This would apply if no other complications are hidden or no immediate change

of situation happen. Care would then be planed according to the patients condition.

Mr. Oxendine: Position the patient in a semi or high fowlers position to

facilitate lung expansion. Check O2 Sat regularly, if below the normal value to

95% - 100%, the nurse may increase the rate of O2 flow according to the
 specific range given by the attending physician. Check for any deteriorating

signs of the hypoxemia, and also check for hypoxia, and hypercapnea by

assessing the capillary refill if more than the normal <2 seconds, colour of the

mucosal membranes, and signs of clubbing of the fingers. Administer the

prescribed medications such as bronchodilators. Provide the appropriate

health teachings of deep breathing, and clearance of secretion. Calm the

patient if anxious. Follow up any ordered laboratory or diagnostic studies and

relay to the AP. Report any health threats immediately.

Mr. Hines: Make sure to check the vital signs efficiently and effectively since

some cardiac medications require special considerations. Check the

availability of the medications and check the medications 3 times by

comparing it with the medication ticket before administering. Once when

taking the medications out of the cabinet, second when preparing, and third

before administering. Check if it is the right patient by asking for their name or

check the hospital band if available. Administer the medications with the right

route, dose, and medication. Always uphold the 10 rights of medication

administration of:

o Right Patient o Right Assessment

o Right Drug o Right Education

o Right Route o Right Documentation

o Right Dose o Right to Refuse

o Right Time o Right Evaluation

 After the administration, check the vital signs after 30 minutes to

assess the effectiveness of the drug or if any further abnormalities occur.

Document all medications given and sign your initials with title and signature.

Continue to monitor patient for any distress. If patient has any pain, initially

provide non-pharmacologic measures to alleviate pain such as distraction

techniques by talking to the patient and therapeutic touch and report to the AP

if pain increases to be prescribed with analgesics. If an ECG or cardiac

monitor is needed, perform an ECG reading and attach the patient to a

cardiac monitor and assess status regularly. Provide the appropriate health

teachings of health maintenance and disease prevention. Calm the patient if

anxious. Follow up any ordered laboratory or diagnostic studies and relay to

the AP. Report any health threats immediately.

QUESTIONS:

1. Mrs. Guangco is a 76 year old patient admitted in the Medical-Surgical

Unit at MRXUH. Upon taking her vital the nurse was able to take a

borderline pulse rate of 98 beats per minute. If there are no other

complications, the nurse is able to imply that an increase in the heart

beat is due to:

a. Increased Workload of the heart c. Fatigue

b. Valsalva Maneuvers d. Decreased Workload of the heart

2. When studying for her board examination, Student Nurse Aspirin is

trying to memorize the 10 right of drug administration. What is the

abbreviation for the 10 rights?

a. MEDICATION c. RIGHT PATIENT

b. DEAR PT RED d. DRUG ADM TOK

3. Student Nurse Alcordo is to administer an Alpha Adrenergic Antagonist

to a patient with hypertension. It is safe to say that the SN has done her

drug study if she identifies that the best time to give the medication is?

a. Morning

b. Bedtime

c. Afternoon

d. Late at Night
 4. An anxious patient arrived in the Emergency Room in MRXUH. The best

way to calm the patient is to?

a. Let the patient sit down

b. Leave the patient alone for a while

c. Ask the patient what is making him anxious

d. Restrain the patient

5. Student Nurse Umali is taking the vital signs of a pediatric patient. It is

safe to say that SN Umali understands the concept of vital signs taking

when he states that the values of a pediatric patient is?

a. The same as with an adult patient

b. Different from an adult patient

c. A & B

d. None of the above

SOURCE:

(Trueman, M.S. (2014). Case Studies in Nursing Fundamentals pg. 158-158.

Retrieved on June 23, 2017)
15 LEAD ECG PLACEMENT

12 LEAD ECG PLACEMENT