KeithRN COVID-19 Case Study
COVID-19 Case Study
John Taylor, 68 years old
Case Study: Student Fill-in PDF
Primary Concept | |||
Infection/Immunity | |||
Interrelated Concepts (In order of Emphasis) | |||
• Clinical Judgment | |||
NCSBN Clinical Judgment Model | Covered in Case Study | NCLEX Client Need Categories | Covered in Case Study |
Step 1: Recognize Cues | ✓ | Safe and Effective Care Environment | |
Step 2: Analyze Cues | ✓ |
| ✓ |
Step 3: Prioritize Hypotheses | ✓ |
| ✓ |
Step 4: Generate Solutions | ✓ |
| |
Step 5: Take Action | ✓ | Health Promotion and Maintenance | ✓ |
Step 6: Evaluate Outcomes | ✓ | Psychosocial Integrity | ✓ |
Physiological Integrity | |||
| ✓ | ||
| ✓ | ||
| ✓ | ||
| ✓ |
Initial Triage Assessment in ED
Present Problem
John Taylor is a 68-year-old African-American male with a history of type II diabetes and hypertension who came to the emergency department (ED) triage window because he felt crummy; complaining of a headache, runny nose, feeling more weak, “achy all over” and hot to the touch and sweaty the past two days. When he woke up this morning, he no longer felt hot but began to develop a persistent “nagging cough” that continued to worsen throughout the day. He has difficulty “catching his breath” when he gets up to go the bathroom. John is visibly anxious and asks, “Do I have that killer virus that I hear about on the news?”
Personal/Social History
John lives in a large metropolitan area that has had over three thousand confirmed cases of COVID-19. He has been married to Maxine, his wife of 45 years and is retired police officer and active in his local church.
Questions
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Patient Care Begins
John is brought back to a room. As the nurse responsible for his care, you collect the following clinical data.
Current Vital Signs
T: 100.3°F/38.8 °C (oral)
P: 118 (regular)
R: 20 (regular)
O2 sat: 92% room air
P-Q-R-S-T Pain Assessment
Provoking/Palliative: “moving makes it worse”
Quality: “achy”
Region/Radiation: “all over”
Severity: 5/10
Timing: continuous
Questions
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Current FOCUSED Nursing Assessment
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
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Caring and the “Art” of Nursing
Questions
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