Description Age: 32 years Provider: J. Bellion MD Allergies: NKDA Code Status: Full code Admit ...

---

Description Age: 32 years Provider: J. Bellion MD Allergies: NKDA Code Status: Full code Admit Wt: 145 lbs (65.7 kg) BMI: 24.9 Nursing Flowsheets Provider MAR NURSING ASSESSMENT & NOTES 7/9 1930 Cardiac: S1 & S2 present. HR regular and even. No ankle edema. 3+ pedal pulses. Respiratory: Breathing regular, even, unlabored. Lung sounds clear bilaterally. No cough. Gastrointestinal: Bowel sounds present and normoactive in all 4 quadrants. Abdomen round, nondistended, non-tender. Last B.M. yesterday, "normal" in appearance. Genitourinary: Urine yellow and cloudy, foul odor. Stated voids small amounts frequently. + dysuria and frequency. Skin: Swelling and redness to the right foot. The client is concerned about a spider bite. Pain: Rates 5/10 flank pain that the client describes as intermittent and sharp. Lines/Drains: Patent 20 gauge peripheral IV in the right forearm. The dressing is clean, dry, intact. No swelling or redness. 7/9 1930 Nursing Note: Assessment completed. See flowsheets. Client apologetic as children are in the room. "I'm sorry they are so loud. They will leave just as soon as their Abuela gets here. Manuel, do not play with her scanner. She needs that to give mama her medicine." Ciprofloxacin administered per order. 7/9 1950 Nursing Note: The client notifies the nurse of feeling itchy and having a sensation of airway tightness. "I don't know what's happening. I feel funny." Noted tongue and lip swelling and audible wheezing. Urticaria noted on client's arm above IV site. 7/9 2002 Nursing Note: The client states, "I don't feel so good." The client's eyes roll back. Client slumps in bed. Not responsive to painful stimuli. No carotid pulse was palpated. Code blue called. Grandmother here as the children were removed from the room and escorted to the waiting room. 7/9 2007 Nursing Note: Return to spontaneous pulse and breathing after epinephrine and defibrillation. Respirations 10, 4L of O2 applied for SpO2 of 95%. Ice packs applied to the groin and axillae. Client prepared for transfer to ICU for close monitoring. Family updated by code team leader. Question 3 Correct Mark 33.33 out of 33.33 QUESTION TEXT Before answering this question, review the client's health information in the EHR. Listen to the client's child. PlayMute Loaded: 0% Progress: 0% -0:12 Download Audio Transcript Determine the nurse's best actions. Select three (3) that apply. Call for a social worker to be with the children. Silence the alarms so that the children are not frightened. Remove the children from the room. Tell the children everything will be okay. Notify the closest relative. Tell the children they can be in the room if they sit quietly. Have security come to prevent the children from disrupting the code. Have the health care provider talk to the children. FEEDBACK Your answer is correct. Debriefing: Great care should be taken when involving the family in the resuscitation process. The children should be removed from the room until they can control enough of their emotions not to disrupt the resuscitation process. Often, a close relative of the client may discern whether the children should see the resuscitation process or not. Having a social worker with the children and providing support is appropriate. The children are currently in escalated distress and should be removed from the situation. Having the health care provider talk to the children is not the best use of resources. It is not appropriate to give false hope or silence alarms. Consider: 1. What other measures could be taken to support this family during the resuscitation process? 2. How are considerations and explanations tailored to assist children in understanding the dying process in different developmental stages? 3. At what age could a parent's child be involved in the decision-making process for the dying parent/patient? The correct answers are: Remove the children from the room. Call for a social worker to be with the children. Notify the closest relative. QUIZ NAVIGATION 12 Flowsheets Provider MAR VITAL SIGN TREND Date Temp °F (°C) HR RR BP SpO2 O2 7/9 1500 99.6 °F (37.8 °C) 105 17 122/74 97% RA 7/9 1900 100.0 °F (37.8 °C) 103 18 118/78 97% RA 7/9 1950 deferred 113 24 98/58 87% RA Provider MAR PROVIDER PRESCRIPTIONS & NOTES 7/9 1955 Prescriptions: Diphenhydramine 50 mg IVP STAT Famotine 100 mg IV in 50 mL 0.9% N.S. over 15 minutes STAT Epinephrine 0.3 mg IVP STAT Continuous telemetry and pulse oximetry monitoring Oxygen 2L continuously to maintain SpO2 above 95% Discontinued: Ciprofloxacin 400 mg/200 mL D5W Place crash cart to bedside NPO status 7/9 2002 Prescriptions: Epinephrine 1 mg IVP STAT Defibrillate at 200 J STAT Continuous telemetry monitoring Continuous end-tidal CO2 monitoring Consult: Chaplain services for family support Begin cooling protocols Transfer: Cardiac ICU services: Post-cardiac arrest care MAR MEDICATION ADMINISTRATION RECORD Medication 7/9 1415 7/9 1700 7/9 1930 Medication: 0.9% Normal Saline Dosage: 1000 mL - 100 mL/hr Route: IV infusion Frequency: Continuous Parameters: Observe for infiltration of IV site or s/s of fluid overload -- -- LJH Medication: Ceftriaxone Dosage: 1 g/50 mL Route: D5W IVPB Frequency: over 30 minutes Parameters: N/A ASE 1415 (administered in ED) -- -- Medication: 400 mg/200 mL Route: D5W IVPB Frequency: over 30 minutes Parameters: N/A -- -- LJH Medication: Ondansetron Dosage: 4 mg/2 mL Route: IVP Frequency: over 1 hr q6h x2 doses Parameters: PRN for nausea -- LJH