Questions

1. What data from the histories are RELEVANT and must be NOTICED as clinically significant by the nurse?
   (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential)
   • RELEVANT Data from Present Problem » Clinical Significance
   • RELEVANT Data from Social History » Clinical Significance
2. What additional clarifying questions does the triage nurse need to ask John to determine if his cluster of physical symptoms are consistent with COVID-19?
3. Based on the clinical data collected, identify what measures need to be immediately implemented using the following clinical pathway.
4. What type of isolation precautions does the nurse need to implement if COVID-19 is suspected? What specific measures must be implemented to prevent transmission?
   • Type of Isolation and its Implementation Components
5. What are the six steps in the chain of infection? Apply what is known about COVID-19 to each step.
6. Is this patient a susceptible host? What step in the chain of infection does proper isolation precautions impact? Why?

Questions

1. What VS data are RELEVANT and must be NOTICED as clinically significant by the nurse?
   (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential Reduction of Risk Potential/Health Promotion and Maintenance)
   • RELEVANT VS Data » Clinical Significance
2. What body system(s) will you assess most thoroughly performing a FOCUSED assessment based on the primary/priority problem? Identify correlating specific nursing assessments.
   (NCLEX: Reduction of Risk Potential/Physiologic Adaptation)
   • PRIORITY Body System » PRIORITY Nursing Assessments

GENERAL SURVEY:

Appears anxious, body tense

NEUROLOGICAL:

Alert & oriented to person, place, time, and situation (x4), generalized weakness

HEENT:

Head normocephalic with symmetry of all facial features. Lips, tongue, and oral mucosa pinkand moist.

RESPIRATORY:

Breath sounds fine dry crackles bilat. with diminished aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, non-labored respiratory effort, episodic non-productive cough

CARDIAC:

No edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees.

ABDOMEN:

Deferred

GU:

Deferred

INTEGUMENTARY:

Skin hot, dry, intact, normal color for ethnicity. Skin integrity intact, skin turgor elastic, no tenting present.

Questions

1. What assessment data is RELEVANT and must be NOTICED as clinically significant by the nurse?
   (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential Reduction of Risk Potential/Health Promotion & Maintenance)
   • RELEVANT Assessment Data » Clinical Significance:
2. Interpreting clinical data collected, what problems are possible? Which problem is the PRIORITY? Why?
   (NCSBN: Step 2: Analyze cues/Step 3: Prioritize hypotheses/NCLEX: Management of Care)
   • Problems » Priority Problem » Rationale
3. What nursing priority(ies) and goal will guide how the nurse RESPONDS to formulate a plan of care?
   (NCSBN: Step 4 Generate solutions/Step 5: Take action/NCLEX: Management of Care)
   • Nursing PRIORITY:
   • GOAL of Care:
   • Nursing Interventions » Rationale » Expected Outcome: