Question Answered step-by-step Nursing Situation Johnny Johns- Peri-op care/Activity Name : Johnny… Nursing Situation Johnny Johns- Peri-op care/ActivityName: Johnny Johns DOB: 07/03/1957 Ht: 68″ Wt: 200lbsAllergies: NKDA, Shellfish, dust mites Code status: Full codeHospital: Lynn Simulation Hospital Unit: Skilled Nursing Facility (SNF)Admitting diagnosis: post coronary artery bypass graft (CABG)PMH: Diabetes mellitus; Meningococcal pneumonia 6 years ago; motor vehicle accident with abdominal trauma 4 years 11 months ago; pressure injury to his right buttock 5 years 10 months ago.PSH: Coronary artery bypass graft (CABG) 1 ½ weeks ago; Open laparotomy with repair to small intestine (Post-op complications wound dehiscence) 5 years 11 months ago.Social history: smoker for 13 years (12 cigarettes per day) HPI: Johnny was admitted to the skilled nursing facility (SNF) for rehabilitation post CABGSBAR to the physical therapistIntroduction: Good morning Mr. G. This is nurse V. I am calling from the Lynn Simulation Hospital SNF about patient Mr. Johnny Johns, 64-year-old male who is post CABG.The situation is: Doctor Smirka has written a consult for PT eval and treatThis is the background: Mr. Johnny Johns was admitted from the Medical-surgical unit today to continue his recovery and rehabilitation. Mr. Johns has PMH of diabetes mellitus and CHF. He smoked cigarettes for over 13 years. He has no known drug allergies.Assessment: On assessment Mr. Johns is A/O X4. Denies pain. No signs of cardiorespiratory distress. Vital signs stable. Incision sites to mid-sternum and right leg intact, no redness or drainage.Recommendation/request: Evaluate Mr. Johns and recommend a treatment plan for activity and mobilityOrders:1. Collaborative1. Physical therapy (PT) evaluation and treatment2. Teach leg exercises2. Nursing1. after physical therapy evaluation:1. Get patient out of bed to chair2. Ambulate patient with walker• Reinforce teaching, range of motion (ROM) exercises1. Assist patient with turning and moving up in bed2. Place antiembolism stocking to unaffected leg3. Pneumatic compression device to both legs while patient is in bedNursing Process/ADPIEAssessmentLack of experience with postoperative rehabilitationDiagnosis (nursing)Deficient knowledgePlanning/Expected outcome/goalPatient will understand the impact of rehabilitation on recovery, and teach back 2 mobility and activity techniques after education and demonstration.Intervention/Implementation/ActionDevelop education plan for patient and family; provide instructions for activity progression; demonstrate and reinforce passive and active range of motion, how to transfer from bed to chair, and how to apply anti-embolism stockings.EvaluationExample: 3/25/2021 1600 patient’s airway is clear after suctioningProvide answers to the following questions including the rationale.1. During preoperative education, the nurse has taught a patient to do leg exercises. How can the nurse best determine if this teaching has been successful? (select the best option) [Ref. CoursePoint Skills 6-2 p. 330]1. Ask whether the patient feels adequately prepared, and offer to answer any questions2. Ask the client to explain the specific benefits of leg exercises3. Ask the client to demonstrate the leg exercises4. Have the client explain the leg exercises in detail2. A client has been admitted to the surgical recovery unit following abdominal surgery. Which nursing intervention occurs during this phase of the surgical experience? (select the best option) [Ref. CoursePoint Fundamentals Review 6-3 p. 321]1. Administering supplementary oxygen as needed2. Introducing deep breathing exercises3. Teaching the meaning of PRN orders for pain medications4. Establishing IV access and administering fluids3. The nurse is caring for a client postoperatively The vital signs are blood pressure 88/50 mmHg, heart rate 110, respirations 24. The client stated the pain in the abdomen will not stop. The abdominal dressing is saturated with fresh blood. Along with notifying the surgeon, what is the nurse’s priority in this situation? (select the best option) [Ref. CoursePoint Skill 6-5 p. 348]1. Reinforce the abdominal dressing2. Provide prescribed pain medication3. Place in supine position4. Assess urine output4. A nurse is ambulating a client. The client catches her foot on the bed frame and begins to fall. How should the nurse best prevent or minimize damage from this fall? (select the best option) [Ref. CoursePoint Skill 9-7 pp. 545]1. The nurse should put his or her feet close together with one foot in front of the other2. The nurse should rock his or her pelvis out on the opposite side of the client3. The nurse should grasp the gait belt and pull the client’s body backward away from his or her body4. The nurse should gently slide the client down his or her body to the floor5. A nurse explains to a client that following her knee surgery, a continuous passive motion machine will be used to promote healing. What benefits of using this machine should the nurse teach the client? (select all that apply) [Ref. CoursePoint Skill 9-13 p. 564]1. Improved healing of a fracture2. Increased rate of joint healing3. Healing a hematoma4. Improving circulation5. Improving range of motion6. Stabilizing respiratory rate6. A client injured her shoulder in a fall and requires a sling. Which action should the nurse perform during and after application of the client’s sling? (Select the best option) [Ref. CoursePoint Skill 9-14 p. 568]1. Ensure the client’s wrist is not enclosed in the sling2. Remove the sling every 2 hours for the first 6 hours to assess circulation3. Position the sling so the client’s arm is at right angle to his or her body4. Assess the client’s active and passive range of motion (ROM) before applying the sling Health Science Science Nursing NUR 12345 Share QuestionEmailCopy link Comments (0)
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