Question Answered step-by-step Mrs. Madsen is a 78-year-old woman who has been taking Warfarin… Mrs. Madsen is a 78-year-old woman who has been taking Warfarin (Coumadin) daily for atrial fibrillation that was diagnosed five years ago. She woke up this morning with the worst headache of her life that is global and rates as a 10/10. Her husband called 911 because her speech became slurred and then she had a seizure that lasted for 1″ and remained sleepy afterward. She is brought to the ED and you are the receiving nurse…1. What is the medical problem that your patient is most likely presenting with? 2. What is the underlying cause /pathophysiology of this concern? 3. Based on the data you have collected, what is your primary concern right now? 4. What interventions will you initiate based on this primary concern? (start with A-B-C priorities) 5. What body system will you most thoroughly assess based on the patient’s chief complaint and primary/priority concern? (start w/A-B-C body systems) 6. What is the worst possible complication to anticipate? (start with A-B-C priorities) 7. What nursing assessment(s) will you need to initiate to identify and respond to quickly if this complication develops? 8. What VS & assessment data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT VS/assessment data: Relationship to primary medical problem: 9. What lab/diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Diagnostic results: Relationship to primary medical problem10. What is the relationship between the following physician orders/meds and your patient’s primary medical problem? (How will mech. of action of these meds/treatments impact this patient at a pathophys. level to help resolve primary problem?) Physician orders: Labetolol 10 mg IV may repeat every 15″ to keep SBP 160-170 Levetiracetam (Keppra) 1000 mg IVPB Seizure pads Fresh Frozen Plasma (FFP) Vitamin K 5mg IV To OR for emergent craniotomy How it will help resolve primary problem: 11. What is the patient likely experiencing/feeling right now in this situation? 12. What can you do to engage yourself with this patient’s experience, and show that they matter to you as a person? Health Science Science Nursing NURS MISC Share QuestionEmailCopy link Comments (0)
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