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    Clinical Reasoning

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    TWINKLE MAE EGAY
    The document provides an ISBAR handoff for Patient Roberto Dutwenty, a 60-year-old male presenting with acute shortness of breath and history of COPD, who has symptoms of pneumonia, tachycardia, fever, and low oxygen saturation. It includes his medical history, current medications, lab and imaging results, vital signs, and physical exam findings, and recommends daily weight monitoring and inquiring if the receiving provider needs anything further.

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    Clinical Reasoning

    Uploaded by

    TWINKLE MAE EGAY
    27 views3 pages
    The document provides an ISBAR handoff for Patient Roberto Dutwenty, a 60-year-old male presenting with acute shortness of breath and history of COPD, who has symptoms of pneumonia, tachycardia, fever, and low oxygen saturation. It includes his medical history, current medications, lab and imaging results, vital signs, and physical exam findings, and recommends daily weight monitoring and inquiring if the receiving provider needs anything further.

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    The document provides an ISBAR handoff for Patient Roberto Dutwenty, a 60-year-old male presenting with acute shortness of breath and history of COPD, who has symptoms of pneumonia, tachycardia, fever, and low oxygen saturation. It includes his medical history, current medications, lab and imaging results, vital signs, and physical exam findings, and recommends daily weight monitoring and inquiring if the receiving provider needs anything further.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    27 views3 pages

    Clinical Reasoning

    Uploaded by

    TWINKLE MAE EGAY
    The document provides an ISBAR handoff for Patient Roberto Dutwenty, a 60-year-old male presenting with acute shortness of breath and history of COPD, who has symptoms of pneumonia, tachycardia, fever, and low oxygen saturation. It includes his medical history, current medications, lab and imaging results, vital signs, and physical exam findings, and recommends daily weight monitoring and inquiring if the receiving provider needs anything further.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    ISBAR

     
    Identify: Good morning Doc, I am Twinkle Mae Egay, a student nurse. I would
    like to endorse to you Patient Roberto Dutwenty, a 60-year-old white male
    who presents to the emergency department on September 24, 2022
    @ 9:00AM with acute onset shortness of breath.
    Situation: The patient came in due to shortness of breath and wanting to
    sleep. He does report difficulty breathing at rest, forgetfulness, mild fatigue,
    feeling chilled requiring blankets, increased urinary frequency, incontinence,
    and swelling in his bilateral lower extremities that is new onset and worsening.
    Subsequently, he has not ambulated from bed for several days except to use
    the restroom due to feeling weak, fatigued, and short of breath.
    Background: Mr. Dutwenty had similar symptoms approximately 1 year ago
    with an acute, chronic obstructive pulmonary disease (COPD) exacerbation
    requiring hospitalization. He is positive for smoking tobacco use at 30
    pack years. He quit smoking 2 years ago due to increasing shortness of
    breath. He denies all alcohol and illegal drug use. Past medical history is
    significant for coronary artery disease, myocardial infarction,
    COPD, hypertension, hyperlipidemia, hypothyroidism, diabetes mellitus,
    peripheral vascular disease, tobacco usage, and obesity. Past surgical history
    is significant for an appendectomy, cardiac catheterization with stent
    placement and nephrectomy. His current medications include Roflumilast 500
    mcg PO q day (given at ED), DuoNeb 1 nebule inhaled q4 hr,
    Spiriva Respimat: 5 mcg inhaled PO q day, budesonide 1 neb q6hr. He is on
    IVF PNSS 1L @ KVO. O2 inhalation @ 8LPM was also initially given to the
    patient via face mask. Spot check was routinely done. He was also given with
    the following medications: hydralazine 50 mg by mouth, 3 times per
    day, hydrochlorothiazide 25 mg by mouth daily, levothyroxine 175 mcg by
    mouth daily, metformin 500 mg by mouth twice per day, nebivolol 5 mg by
    mouth daily, aspirin 81 mg by mouth daily, vitamin D3 1000 units by mouth
    daily, clopidogrel 75 mg by mouth daily, isosorbide mononitrate 60 mg
    by mouth daily, and rosuvastatin 40 mg by mouth daily.His laboratory and
    Radiological tests as of September 24, 2022, X-Ray
    result reveals pneumonia, WBC at 14,000, RBC & platelets normal. Stool and
    urine analyses are also normal.
    Assessment: Patient’s Dutwenty’s vital signs  for the RR 26 bpm the patient is
    tachypneic, T 38.2C he is also febrile, PR 110bpm he is also tachycardic, and
    his SPO2 92% which is below the normal range, with irregular, shallow,
    breathes through mouth, uses accessory muscle for breathing, unable to
    breathe in supine position, audible breath sounds within few feet. Auscultation
    reveals bilateral course crackles on lower lobes with decreased breath sounds
    at posterior area. The patient is on IVF of PNSS 1L @ KVO and an O2
    inhalation @ 8LPM was also initially given to the patient via face mask. 
    Recommendation: Can we weigh the patient daily to monitor the swelling in
    his bilateral lower extremities that is new onset and worsening. And is there
    anything you need me to do or organize before you come to see the patient?

    Clinical Reasoning (Ethico-Moral-Legal Considerations)

    Nursing As a student nurse, I must first identify the values that may influence
    Action and relate to Sir Roberto's decision. I will discuss the process to help
    him decide, starting with examining the possible benefits and
    consequences he will face whether he gets the influenza vaccine or
    not, and making sure that he will understand the result. Moreover, I will
    give him the will to choose freely without external influence to ensure
    wise decisions, and we will verify the effects of the decision. A
    conversion like this will depend on the nurse's responsibility and
    relationship with clients. As student nurses, we have to explain
    thoroughly to encourage them and make sure that it is reasonable or
    proportionate in the client's understanding for it to be useful for the end
    client, which may change his decision.

    Ethical The ethical principle that needs to be upheld is the value of autonomy.
    Principle Every client is unique and they have the right to choose their personal
    Upheld goals, so we student nurses must treat clients with consideration as
    long as it will not harm the client. Since many of the germs that cause
    respiratory diseases are spread by droplets in their close contact, we
    really must encourage Sir Roberto to get a vaccine to protect himself.
    Next is the concept of beneficence, or doing good, such as
    implementing actions that the client can benefit from, like encouraging
    her and teaching him to read from reliable sources/studies, and
    nonmaleficence, for not placing the client at risk of harm by giving her a
    vaccine that can protect him.
    C I am concerned with what my co nurses did. I noticed that they were not giving

    Antibiotics on time.

    U I am comfortable seeing them doing that. Giving antibiotics improperly might

    Increase the chance of the client developing medicine -resistant bacteria

    S This is a safety issues that needs to be addressed. Antibiotics need to be given on

    Time so that the maximum affect circulates evenly over the course of the day and

    To prevent the bacterium form defending itself and to guarantee that the illness

    Caused by the bacteria is eliminated

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