Question
Answered step-by-step
Asked by eakpovwa
Jeremiah Gaufich, who is a 62-year old client who is riding his horse when the horse becomes spooked and throws him off. Jeremiah feels a sudden pain in his back and numbness and tingling of his lower extremities. He calls for help, and is taken to the emergency department where it is revealed he has suffered L1-L2 vertebral fracture and spinal nerve damage. He is treated in the acute care setting with effective spinal immobilization and medication until he’s stable and is ready for transfer to the NurseThink rehabilitation facility. Jeremiah’s spinal injury results in sensory defects and motor loss below the level of damage, with varying control of his legs and pelvis. The provider feels he will eventually return home having a good sitting balance with full independent use of a wheelchair. He may be able to ambulate short distances with leg braces. 1. Based on the priority concerns what action should the nurse perform first? a. Assess his ability to move his extremities. b. Maintain spinal precautions with immobilization. c. Assess his distal responses to pinprick and vibration. d. Discuss the signs and symptoms of risks the client may have. 2. Review this image and the areas of the body that impact sensation. Based on Jeremiah’s injury, what should the nurse anticipate as defects and why? After gathering a history and performing a head-to-toe assessment, the nurse determines that because of Jeremiah’s injury, he has lost motor and sensory function below the level of injury. He currently has been prescribed a lumbar brace, and foot drop splints. 3. Describe the use of each of these devices. What teaching will be needed for Jeremiah? 4. What is the purpose of a reflex hammer? What should the nurse expect to evaluate by performing this type of assessment? After the shift assessment, the nurse documents vital signs and plans to complete subsequent focused assessments, focusing in on the parts of the nervous system affected by Jeremiah’s condition. BP 130/78; HR 72; R 14; Sats 96% Room air; Temp 100 F; Pain-0; Weight 186 lbs. It is determined that Jeremiah has lost function of bowel and bladder and is on a bowel and bladder training program. He learns initiate timed urinary catheterization and rectal suppositories. Jeremiah has been able tocomplete a return demonstration on how to utilize a urinary catheter and rectal suppository. However, the urine return appears slightly bloody, dark, and cloudy with a foul odor. 5. Prepare SBAR telephone conversation for the provider. The provider for Jeremiah prescribes a urinalysis with culture and sensitivity, complete blood count and international normalized ratio, INR and IV antibiotics. Each of the newly hired nurses has five clients and Margarita oversees the care they are providing, acting as a mentor and resource nurse throughout the shift. The team members form a huddle at the beginning of the shift and determine a plan for delivery of safe and effective care for the day. In preparing for the professional nurse’s role as a mentor, what best describes the goals of Margarita’s leadership position? 6. List out several qualities you feel that would make Margarita a good leader and mentor. Margarita delegates to the new nurse the task of assisting Jeremiah from the wheelchair to the bed. The nurse responds, “I understand this is in my job description, but this is the first time I will have done this with a full wheelchair dependent client. Can you show me what to do?” 7. How should Margarita respond? 8. Which tasks can the nurse safely delegate to the unlicensed assistive personnel (UAP)? Select all that apply. a. Monitor vital signs and record the results. b. Collect and assess urine from straight catheterization. c. Monitor intake and output, and record the results. d. Assist the client from the wheelchair to the bed. e. Reposition client and evaluate skin and pressure areas for breakdown. 9. What resource can the new nurse use that will provide information and is considered the determinant for the decision to delegate within the legal scope of delegation rules? Several of the rehabilitation clients require medications. Margarita gathers the new nurses to learn how the team administers several medications to multiple clients each day. The nurses are expecting a standardized medication dispensing system, but instead, there is a cart with wheels and several medications contained within drawers. The nurses push the cart through the hallway to each room, where they administer the medications. The residents do not wear identification, but there is a chart at the door with their name and client identification number. Nurses Anne and Kevin are working together. Anne prepares the medications and places them into a cup. She hands the pills to Kevin who then enters the client’s room to deliver the medicines. Kevin enters Jeremiah’s room, hands him the medicine cup with a tablet in it, and says “here’s your sertraline.” Jeremiah swallows the tablet with water. Kevin returns to the medication cart and realizes that there are two identical bottles of sertraline next to each other on the cart. One bottle is labeled “50 mg/tablet”, and the other bottle is labeled “100 mg/tablet”. He realizes that the wrong tablet was placed into the medication container by Anne and that he administered to Jeremiah. Kevin tells Anne “I think you prepared the wrong tablet that I gave to Mr. Goldfinch. Do you think he’ll be okay? Anne responds, “I think it’ll be okay, it’s just an antidepressant, and there are limited harmful side effects.” 10. The nurses discuss how the error could have been prevented. What actions should the nurse have taken to avoid the incident? There once was a saying that said, to err is human. Because we know this to be true all too well, facilities have incident and risk management. 11. Is it ever okay to not report when you’ve made a mistake in client care, such as giving the wrong medication? Why or why not? 12. Do you know the procedure to follow if there was ever an incident in your facility in which you worked? What are the procedures if the injury is not towards the client, but you actually suffered the injury? Although Jeremiah suffers no consequences from receiving the wrong dose of the medication, it led the team to investigate and modify the normal operations of medication administration. The nursing supervisors have collected data which revealed medication errors have been on the rise in the rehabilitation facility. Funding was allocated to promote a safer environment with less risk for errors to occur. They have been working with team members and have implemented the new method for medication administration. The institution completed a follow-up investigation and found a 95% reduction in medication administration, confirming that a positive outcome was achieved. 13. Review/Describe the 5 rights of medication administration.
SCIENCE
HEALTH SCIENCE
NURSING
