Carrington College – NURS 231 Nursing Process VI: Medical-Surgical Nursing IV
Clinical Reasoning Table – submitted CRT must be in a Word document in
... [Show More] the correct format
Student Name: Kendall Harrison Clinical Reasoning Table (indicate which one) 1 – 2 – 3 – 4
Brief Patient Background of Current Admission (e.g. events leading to admission and admitting diagnosis, current state of patient condition):
Patient was involved in skiing accident on 1/22. Was resuscitated while en route to Renown hospital. Patient presented to the hospital with may
injuries: Respiratory failure from trauma, traumatic hemothorax, acute blood loss anemia, contusion of both lungs, closed fracture of multiple ribs
on right and left side, pneumomediastinum, spleen laceration, bi-lateral lung laceration, multifracture of thoracic spine.
Patient is stable during initial assessment, sedated, responds to stimuli and follows commands as given. However, patients condition changes rapidly
following the doctors’ orders to remove the mechanical ventilation. Patient becomes unstable. Unable to maintain oxygen saturation and O2
saturation drops rapidly, within minutes O2 sat drops to 68% and patient is fitted with high flow nasal cannula delivering 40L/min.
Code Status: FULL Allergies: NONE
Past Medical/Surgical History: NONE
Head-to-Toe Assessment
(your shift assessment; do
not include historical or
admission data)
Top 2 Problem
Statement(s) using the
syntax of Basic Human
Need R/T …… aeb ……
Include the “aeb” for At
Risk Problems as well
Goals
Must be congruent with the
problem and measurable.
One goal per problem.
Nursing Actions
What did you actually do
to help the patient meet the
goal? Be specific about any
medications you gave, i.e.
med, dose, route
Evaluation/Reformulation
Did the patient meet the
goal – Yes or No. Why yes
or why no? Could
something different have
been implemented? Was
the goal realistic?
Vital Signs (T, P, R, BP, O2
Sat, include oxygen
amount)
0800:
T 98.1
P 91
R 15
BP 126/80
O2 Sat 98 on 30%O2
1200 (ICU/CIC only):
T 100.1
Problem Statement #1:
Ineffective breathing
pattern related to decreased
lung expansion caused by
multipole broken ribs, and
blood entering the lung
cavity also decreasing the
lungs ability to expand and
fill with air spontaneously.
As evidenced by
deteriorating O2 saturation,
short-rapid breathing
pattern, abnormal arterial
Goal #1:
Maintains breathing pattern
to retain ABG’s within
normal parameters
Goal #2:
Decrease in self-reported
pain, decrease in pain
related behaviors, return to
baseline b/p, RR, pulse,
temperature.
Interventions for Goal #1:
1. HOB to 60 degrees to
maximize
diaphragmatic
breathing and vital
capacity.
2. Coached patient to
breathe deeply and
remain awake with eyes
open to focus on breath
rate and depth.
3. Suctioned airway and
encourage patient to
cough.
Evaluation/Reformulation
for Goal #1:
1. Goal not met.
After implementing the
interventions, patient
became stable. ABG’s
did not return to normal
with a change in CO2
going from 80 to 50.
Breathing pattern was
still shallow, but O2
saturation returned to
baseline, B/P, RR, Pulse
and Temp also returned
to normal parameters. [Show Less]