[Solved]: Single-Episode Case Clinical Situation A 24-year old…

Single-Episode Case Clinical Situation A 24-year old woman was a passenger in her boyfriend’s car when their car was in a motor vehicle crash. The damage to her side of the car resulted in severe injuries to her right leg and arm. She was admitted yesterday to the hospital with a fracture of her tibia and fibula (“tib-fib” fracture), massive soft tissue and leg muscle damage, and a right wrist fracture. She also has multiple contusions and superficial lacerations. Both her leg and wrist are in temporary splints and elevated on pillows with ice packs until she is cleared for surgery. The client is right-handed. The night nurse reported that her parents are staying with her and that the client has been crying most of the night. The day nurse performs a shift assessment and documents the following: • Reports that her pain level has increased from a 5 to a 9 even though she recently received morphine via IV push. • Reports numbness and tingling in her injured leg and foot • Toes on her right foot are colder and paler than those on the left foot • Right pedal pulse not palpable or located via Doppler • Oral temperature = 98.4 degrees F (36.9 degrees C) • Apical pulse = 88 BPM • Respiratory rate = 28 breaths/minute • Blood pressure = 132/84 mmHg • States that she “wish she had died in the accident” • Has difficulty answering questions because she is very emotional and crying • Refuses to eat stating that she is not hungry • Has a urinary catheter in place which is draining amber urine Decision-making (clinical judgment) requires high cognitive-level questions to stimulate student thinking. One approach to help students apply the six cognitive skills of the NCSBN Clinical Judgment Measurement Model is to structure the questions to reflect each of those skills (indicated in brackets). 1. What assessment information in this patient situation is the most important and of immediate concern for the nurse? (Hint: Identify the relevant information first to help you determine what is most important.) [Recognize Cues] 2. What patient conditions are consistent with the most relevant information? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.) [Analyze Cues] 3. Which possibilities or explanations are most likely to be present in this patient situation? Which possibilities or explanations are the most serious or priority? (Hint: Consider all possibilities and determine their urgency and risk for this patient.) [Prioritize Hypotheses] 4. What actions would most likely achieve the desired outcomes for this patient? Which actions should be avoided, are irrelevant, or are potentially harmful? (Hint: Determine the desired outcomes first to help you decide which actions are appropriate and those that should be avoided.) [Generate Solutions]