capstone

Fundamentals Take Home Exam

Ms. S is a 58-year-old African American woman who is directly admitted to your unit with complaints of chest pressure and indigestion associated with nausea and vomiting. She started feeling ill about 3 hours before admission. She told the nurse she tried drinking water and took some bismuth subsalicylate (Pepto-Bismol) that she had in her bathroom medicine cabinet. She also tried lying down to rest, but none of these actions helped. She says, “It just gets worse and worse.” She rates the pain 5/10 and says that it is a dull, achy pain that stays in the middle of her chest. Ms. S has been under a physician’s care for the past 12 years for management of hypertension and swelling in her ankles. She takes a “pink pill and a water pill.” She was a smoker but quit 1 year ago.

Admission laboratory tests, including levels of cardiac markers, were performed and a 12-lead electrocardiogram (ECG) was taken.   The ECG shows sinus tachycardia with frequent premature ventricular contractions (PVCS…).

Ms. S’s vital sign values on admission are as follows:

Blood Pressure: 174/92 mm Hg

Heart Rate: 120 to 130 beats/min, irregular

Oxygen saturation: 94% on room air

Respiratory rate: 30-34 breaths/min

Temperature: 99.8 Degrees F (oral)

 

  1. Write an SBAR note that would be used to discuss the case with the physician.

 

  1. Explain and give rationale for your recommendations (the “R” of the SBAR)

 

  1. Of the recommendations that you suggest to the physician, which do you implement first? Support your answer with rationale. Be sure to support why the other orders/medications would not be given first.
  2. You assign the nursing assistant the task of taking the patient’s vital signs every 15 minutes and recording the vital sign values in the electronic chart. Later you check the chart and discover that the vital sign measurements have not been recorded.   What is your best response to the nursing assistant?

 

  1. Once Ms. S has stabilized she says to you “I suppose I have to change my diet. What am I supposed to eat now?” What type of a diet would you suggest for Mrs. S? Support your answer with rationale.

 

  1. Write a nursing care plan to include subjective and objective data, 1 nursing diagnosis, NOC, and NIC. Be sure to include rationale for the NIC. The nursing diagnosis maybe of your choosing but should be related to the scenario above.

 

 

  1. Write 1-2 paragraphs reflecting on what you learned through this project.

 

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