Which actions should be avoided or are potentially harmful

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Reference no: EM133963971

Assignment

Case Study

Perfusion Overview

An 83-year-old female is at the doctor's office for complaints of leg pain. The patient states, every time I walk to the bathroom or to my car, both of my calves hurt a lot." "I have to stop walking and sit down and rest. My legs also feel numb at times with tingliness." The patient also informed the nurse that "I get dizzy at home and I have fallen." "When this occurs, I am sometimes short of breath." Based on the numerical pain scale, the patient states, "my pain is a 10."

The patient has a history of hypertension (HTN), coronary artery disease (CAD), osteoarthritis, and smoking for 30 years. The patient denies of smoking currently. Surgical history includes quadruple coronary artery bypass graft 15 years ago. The patient's diet consists of red meat with "some" vegetables and fruit. The patient takes aspirin 81mg po daily, lisinopril 20mg po bid, metoprolol 25mg po bid, and atorvastatin 80 mg po daily. The daughter is with her mother in the office.

The nurse's focused assessment findings are: Heart sounds are S1 S2, Bilateral lower extremities are cool to touch and pallor with cyanosis of the left toes. Bilateral dorsalis pedis are 1 with edema of the left foot. Patient denies of any chest pain or shortness of breath. Lung sounds are clear in all lobes.

Clinical Judgement Challenge:

A. Recognize Cues: What assessment information in this client situation is the most important and immediate concern for the nurse? (Hint: Identify the relevant information first to determine what is most important.)

B. Analyze Cues: What client conditions are consistent with the most relevant information? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.)

C. Prioritize Hypotheses: Which possibilities or explanations are most likely to be present in this client situation? Which possibilities or explanations are the most serious? Get the instant assignment help. (Hint: Consider all possibilities and determine their urgency and risk for this client.)

D. Generate Solutions: What actions would most likely achieve the desired outcomes for this client? Which actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes first to decide which interventions are appropriate and those that should be avoided.)

E. Take Action: Which actions are the most appropriate and how should they be implemented? In what priority order should they be implemented? (Hint: Consider health teaching, documentation, requested health care provider orders or prescriptions, nursing skills, collaboration with or referral to health team members, etc.)

F. Evaluate Outcomes: What client assessment would indicate that the nurse's actions were effective? (Hint: Think about signs that would indicate an improvement, decline, or unchanged client condition.)

Reference no: EM133963971

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