casestudy

Nursing Skills & Reasoning

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Blood Transfusion

1. Which findings from the present problem are most important and noticed by the nurse as clinically significant?

Most Important Findings Clinical Significance

Procedural Safety Principles: Blood Administration

2. What will you do if you have not performed blood administration in the clinical setting?

3. If the nurse was going to administer another unit of packed red blood cells (PRBC), what supplies does the nurse

need to gather?

4. Review and summarize essential steps and knowledge the nurse will apply to administer the remainder of this
transfusion safely.

5. What will the nurse communicate to educate the patient or family about the need for this procedure and what to
expect?

Nursing Skills & Reasoning

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form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN

Evaluation

6. You collect the following assessment data. Make a clinical judgment for each finding by placing an “x” in the
appropriate column if the finding is expected or unexpected.

Assessment Finding Expected Unexpected
T: 98.2 F/36.8 C (oral)
P: 108 (regular)
R: 25 (regular)
BP: 128/83
O2 sat: 88% RA
Appears anxious
Breathing rapidly
Skin is cool and clammy

7. Is the overall status of the patient:

a. Improved
b. Declined
c. No change

8. Complete the table below for each home medication.

Medication Pharm. Class Mechanism of Action Expected Outcome
Metoprolol

Lisinopril

Furosemide

Ferrous gluconate

Potassium chloride

9. Which home medication(s) that were not taken would have the greatest impact on his current status?

Medication Rationale

Nursing Skills & Reasoning

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form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN

10. Calculate the patient’s total intake and output, then interpret the significance of your findings.
Intake and Output Clinical Significance

11. What clinical data is most important and must be recognized as clinically significant by the nurse?

Most Important Data Clinical Significance

12. To interpret the clinical data collected, list at least two possible problems for this patient. Which problem is the

priority?
Possible Problems Priority Problem Pathophysiology of Priority Problem

13. After evaluating the patient, identify the current nursing priority and which action(s) the nurse should take. List

interventions by priority and the expected outcome.
Nursing Priority
Priority Intervention(s) Rationale Expected Outcome

Nursing Skills & Reasoning

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form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN

14. Recognizing a potential problem, you use Identify-Situation-Background-Assessment-Recommendation (ISBAR)
to update the provider. Summarize what you would communicate for an ISBAR report.

I identify Specify who you are/where you work.

• Yourself: name/position/location

• Patient: name/age/gender

S situation What is the problem/reason for contact?

Concise summary of primary problem:

B background If urgent, state concern. Provide concise/relevant history

• Primary problem/diagnosis:

• Day of admission/post-op day #:

• Relevant past medical history:

• Relevant treatments/interventions:

A assessment Assessment of the situation using the most important clinical data.

State your concern by communicating
concerning clinical data:

• Vital signs

• Nursing assessment

• Lab/diagnostic results

Trend of most important clinical data
(stable-increasing/decreasing):

R recommendation Request specific advice/interventions. Clarify expectations.

• Nurse suggestions to advance the plan
of care:

• What do you recommend?

• Repeat and state back new
orders/confirm plan of care:

Nursing Skills & Reasoning

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form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN

15. Identify the rationale for each provider order and its expected outcome.

Provider Orders Rationale Expected Outcome
Furosemide 40 mg IV push

Discontinue blood
transfusion

Apply oxygen to maintain
oxygen saturation >92%

Dosage Calculation: Furosemide 40 mg IV push

Medication

Time frame to
Administer

Show Work Volume to Administer

16. Which findings are expected if the nursing and medical intervention(s) were effective?

Expected Findings Rationale

Nursing Skills & Reasoning

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form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN

17. The nurse has implemented the medical and nursing plan of care. One hour later, you collect the following
assessment data below.
For each finding, make a clinical judgment by placing an “x” in the appropriate column if the patient’s
condition has improved, has not changed, or has declined.

Assessment Finding Improved No Change Declined
Urine output: 750 mL
HR: 89/minute
RR: 18/minute non-labored
BP: 124/80
O2 sat: 96% room air
Crackles persist in bases but are not as pronounced
Resting comfortably appears less anxious

18. Is the overall status of the patient:

a. Improved
b. No change
c. Declined

Documentation
Write a concise nurse’s note to document what was most important in the medical record.

Nurse Reflection
To strengthen your clinical judgment skills, reflect on your knowledge and the decisions made caring for this patient by
answering the reflection questions below.
Reflection Question Nurse Reflection
As you worked through this
simulation, how did it make you
feel?

What did you already know and do
well on this simulation?

What areas do you need to
develop/improve?

What did you learn? How will you
apply what was learned to improve
patient care?

1. Most Important Findings: History of heart failure
   Iron deficiency anemia
   low hemoglobin
2. Clinical Significance: low hemoglobin needs blood tranfusion
   Heart failure can cause breath difficulties
3. 2: As a student nurse I can not administrater blood alone without supervision, so I will ask charge nurse and also look at the hospital policy.
4. need to gather: I will need gloves, vital sign machine, blood tubing with fliter, IV pump and normal saline
5. transfusion safely: Check prescriptions for allergy, expiration, virefied orders with second nurse check vitals before blood tranfusion monitor patient during tranfusion watch for side inffect and decumention.
6. expect: Educate patient that blood tranfusion will help with their hemonglobin, they should wash and report these symptoms; shortness of breath, and chest pain.
7. Assessment Finding:
8. ExpectedT 982 F368 C oral: x
9. UnexpectedT 982 F368 C oral:
10. ExpectedP 108 regular:
11. UnexpectedP 108 regular: x
12. ExpectedR 25 regular:
13. UnexpectedR 25 regular: x
14. ExpectedBP 12883: x
15. UnexpectedBP 12883:
16. ExpectedO2 sat 88 RA:
17. UnexpectedO2 sat 88 RA: x
18. ExpectedAppears anxious:
19. UnexpectedAppears anxious: x
20. ExpectedBreathing rapidly:
21. UnexpectedBreathing rapidly: x
22. ExpectedSkin is cool and clammy:
23. UnexpectedSkin is cool and clammy: x
24. Medication:
25. Pharm ClassMetoprolol: Beta blocker
26. Mechanism of ActionMetoprolol: reduce heart rate
27. Expected OutcomeMetoprolol: lower heart rate
28. Pharm ClassLisinopril: ACE inhabitor
29. Mechanism of ActionLisinopril: lower BP
30. Expected OutcomeLisinopril: lower BP
31. Pharm ClassFurosemide: loop diuretic
32. Mechanism of ActionFurosemide: Increase urine output
33. Expected OutcomeFurosemide: reduce fluid retention
34. Pharm ClassFerrous gluconate: iron suppliment
35. Mechanism of ActionFerrous gluconate: Provide essential iron
36. Expected OutcomeFerrous gluconate: prevention of iron deficiency enemia
37. Pharm ClassPotassium chloride: electrolyte suppliment
38. Mechanism of ActionPotassium chloride: replaces potassium
39. Expected OutcomePotassium chloride: prevention of hypokalemia
40. MedicationRow1: furosemide
41. RationaleRow1: Furosemide, because it causes fliud build up
42. Intake and OutputRow1: Blood tranfusion
43. Clinical SignificanceRow1: excess fluid causes respiratory issue, like SOB
44. Most Important DataRow1: Heart failure and rapid breathing
45. Clinical SignificanceRow1_2: fluid overload
46. Possible ProblemsRow1: fluid overload
    rapid breathing
47. Priority ProblemRow1: fluid overload
48. Pathophysiology of Priority ProblemRow1: excess fluid build-up place critical strain on the heart.
49. Nursing Priority:
50. Priority InterventionsRow1: Improving breathing
51. RationaleRow1_2: administrater furosemide, notify provider and applying oxygen,
52. Expected OutcomeRow1: improving breathing
53. I identify:
54. Specify who you arewhere you workYourself namepositionlocation Patient nameagegender: Nurse Lucy Myers, RN nurse on the medicine floor

    PT. is Andre Ronaine, 64yrs male PT.

55. S situation:
56. What is the problemreason for contactConcise summary of primary problem: Rapid breathing during tranfusion
57. B background:
58. If urgent state concern Provide conciserelevant historyPrimary problemdiagnosis Day of admissionpostop day Relevant past medical history Relevant treatmentsinterventions: History of heart failure, Iron deficiency anemia and low hemoglobin
    Admited this morning
    date of adnission, N/A
    Heart failure
    Tranfusion
59. A assessment:
60. Assessment of the situation using the most important clinical dataState your concern by communicating concerning clinical data Vital signs Nursing assessment Labdiagnostic results Trend of most important clinical data stableincreasingdecreasing: Pluse is 108, rispiratory 25 and O2 is 88%

    PT. vital signs

    Iron deficiency and low hemoglobin

61. R recommendation:
62. Request specific adviceinterventions Clarify expectationsNurse suggestions to advance the plan of care What do you recommend Repeat and state back new ordersconfirm plan of care: Give diuretics

    Give furosemide

    Continue to monitor Pt vitals

63. Provider Orders:
64. RationaleFurosemide 40 mg IV push Discontinue blood transfusion Apply oxygen to maintain oxygen saturation 92: To eliminate fluid overload

    Stop more overload

    To increase oxygen level

65. Expected OutcomeFurosemide 40 mg IV push Discontinue blood transfusion Apply oxygen to maintain oxygen saturation 92: Enhance rispiration
66. Administer: 1-2 minutes
67. Show Work: 40mg/100mg =0.4×10=4ml
68. Expected FindingsRow1: O2 level>92
    rapid breathing
69. RationaleRow1_3: To improve gas exchange
70. Assessment Finding_2:
71. ImprovedUrine output 750 mL: x
72. No ChangeUrine output 750 mL:
73. DeclinedUrine output 750 mL:
74. ImprovedHR 89minute: x
75. No ChangeHR 89minute:
76. DeclinedHR 89minute:
77. ImprovedRR 18minute nonlabored: x
78. No ChangeRR 18minute nonlabored:
79. DeclinedRR 18minute nonlabored:
80. ImprovedBP 12480: x
81. No ChangeBP 12480:
82. DeclinedBP 12480:
83. ImprovedO2 sat 96 room air: x
84. No ChangeO2 sat 96 room air:
85. DeclinedO2 sat 96 room air:
86. ImprovedCrackles persist in bases but are not as pronounced: x
87. No ChangeCrackles persist in bases but are not as pronounced:
88. DeclinedCrackles persist in bases but are not as pronounced:
89. ImprovedResting comfortably appears less anxious: x
90. No ChangeResting comfortably appears less anxious:
91. DeclinedResting comfortably appears less anxious:
92. Write a concise nurses note to document what was most important in the medical record: Furosimide IV push was administrater to pt. during blood transfusion, Pt experienced rapid breathing.
93. Reflection Question:
94. Nurse Reflection: It was somehow challenging
95. Nurse ReflectionWhat did you already know and do well on this simulation: regonizing and understanding some the problem
96. Nurse ReflectionWhat areas do you need to developimprove: monitoring for adverse effects
97. Nurse ReflectionWhat did you learn How will you apply what was learned to improve patient care: I have learned that monitoring the patient closely and washing up for symptoms like, chest pain and shortness of breath it’s very essential.
    for patient care
98. Text1: 4 ml