Case Study: The nurse is caring for a client who was admitted to the medical-surgical unit after surgery for a cardiac condition. The nurse is caring for the client on postoperative day number two. The nurse notes the incision on the client's chest is slightly red and inflamed directly over the incision site. The client complains of the incision site feeling "tender" but not painful. The nurse notes a scant amount of serosanguinous drainage at the distal end of the incision. The incision is well-approximated and intact with staples present. The client asks about the incision being infected and requests that the nurse contact the health care provider to report their concerns. The nurse reassures the client that the incision appears normial but agrees to leave a note for the provider indicating the client's concerns. The client's vital signs are all within normal limits.
Recognize Cues (Assessment)
a. Ideratify the relevant factors that the nurse used to determine the appropriate response to the client's concerns.
Analysis Clues (Analysis)
a. What are the client's needs related to their concerns about the incision?
b. Identify the potential complication(s) the client could experience.
Prioritize Hypotheses (Analysis)
a. What is the nurse's priority action, based on the client's needs?
Generate Solutions (Planning)
a. Identify the optimal client outcome based on the information about the client's condition in the scenario.
Take Actions (Implementation)
a. What education will the nurse include for the client, regarding their incision and potential for infection?
b. What interventions will the nurse perform to reduce the risk of infection in the client?
Case Study: After reviewing the client's medical record on postoperative day number four, the nurse notes
the following information: temperature 100.1deg F(37.8deg C) and white blood cells are 13,500mm3 mm3.
6. Evaluate Outcomes (Evaluation)
a. How will the nurse evaluate whether the optimal client outcome (identified previously) has been met?
Case Study: The nurse is caring for a client who was admitted to the medical-surgical unit after surgery for a cardiac condition. The nurse is caring for the client on postoperative day number two. The nurse notes the incision on the client's chest is slightly red and inflamed directly over the incision site. The client complains of the incision site feeling "tender" but not painful. The nurse notes a scant amount of serosanguinous drainage at the distal end of the incision. The incision is well-approximated and intact with staples present. The client asks about the incision being infected and requests that the nurse contact the,health care provider to report their concerns. The nurse reassures the client that the incision appears normal but agrees to leave a note for the provider indicating the client's concerns. The client's vital signs are all within normal limits. 1.Recognize Cues(Assessment) a.ldertify the relevant factors that the nurse used to determine the appropriate response to the client's concerns. 2.Analysis Clues(Analysis) a. What are the client's needs related to their concerns about the incision? b. Identify the potential complication(s) the client could experience. 3. Prioritize Hypotheses (Analysis) a. What is the nurse's priority action, based on the client's needs? 4.Generate Solutions (Planning) a.ldentify the optimal client outcome based on the information about the client's condition in the scenario 5.Take Actions (Implementation) a. What education will the nurse include for the client,regarding their incision and potential for infection? b.What interventions will the nurse perform to reduce the risk of infection in the client? Case Study:After reviewing the clients medical record on postoperative day number four, the nurse notes the following information: temperature 100.1F (37.8C) and white blood cells are 13,500 mm3 (5,000-10,000 mm3). 6.Evaluate Outcomes (Evaluation a.How will the nurse evaluate whether the optimal client outcome (identified previously) has been met?
