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NR 305 Week 8 Topic 8 Discussion, Rapid Assessment of a Client
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NR 305 Week 8 Topic 8 Discussion, Rapid Assessment of a ClientPlease choose one of the patient scenarios below. Next, complete a rapid assessment, and provide a SBAR
report to a classmate. Remember to include all concepts of patient safety, standard precautions, and
professional standards.
1. You are covering for a coworker who is off the floor for lunch, when you suddenly hear a loud crash
coming from a nearby patient room. You quickly run in and discover Mr. Johnson who was admitted
yesterday with a diagnosis of cerebral vascular accident (CVA) unconscious on the floor between the
bed and the bathroom.
2. You are called to the room of 2-year-old Jonah by his mother who states the child has suddenly
started breathing very loudly and does not look right. Upon entering the room you quickly recognize
that the child is in respiratory distress as his lips are cyanotic and the use of accessory muscles is
evident.
3. You are in the process of admitting Ashley, a 27 year old who is 28 weeks pregnant with her first
child, to the obstetric unit for complaints of headache, dizziness, and swelling of her lower extremities
when she suddenly begins seizing.
Now it's time to pull together everything we went over in this course and show how you can assess a patient.
Post
Ashley seems to have been admitted with signs of preeclampsia, which includes her complaint of headaches
and dizziness. Classic symptoms include hypertension, and proteinuria (Jarvis, 022015, p. 826). Urine
analysis for proteinuria should be done using a clean-catch specimen to prevent contamination. Indicators of
poor cerebral perfusion such as continued headaches, drowsiness, and mental confusion might be precursors
of seizures.
I would conduct patient history to assess for risk factors. Eclampsia risk factors include nulliparity,
overweight, uncontrolled hypertension, diabetes mellitus (DM), renal disease, and lack of prenatal care
(Schub, 2016). A Physical appearance of generalized edema with rapid weight gain can be an early sign
of eclampsia. Other assessment findings should include blood pressure and urine output. During a seizure, I
would remain with Ashley and press the emergency bell or call light for assistance. Ashley would be guided to
a safe position to prevent a fall injury. A side lying position would help increase placental circulation. Her
airway would also need to be protected.
Situation: My name is Marlon RN and I was in the process of admitting a patient who began to have a seizure.
Background: Ashely, a 27 year old female, is 28 weeks pregnant with her first child. She was being admitted
for complaints of headaches, dizziness and swelling in her legs.
Assessment: I would state vital signs and emphasize any elevated blood pressure readings. Note any visual
disturbances, proteinuria, facial edema, and epigastric pain from possible liver enlargement. Describe
changes in behavior, mental confusion, and reflexes, which may indicate cerebral irritability.
Recommendation: Patient needs immediate attention and possible magnesium sulfate administration to
control eclamptic seizures and antihypertensives for blood pressure management. I would also suggest
ordering stat lab studies for hepatic and renal function. Patient should be kept in quite environment with lights
and noise to a minimum to reduce stimulus.
Reference
Jarvis, C. (2015). Physical Examination and Health Assessment, 7th Edition
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