Competency

Determine appropriate responses when integrating situated cognition into clinical reasoning.

Scenario

One week ago, you started your dream job as an orthopedic nurse at a Level 1 Trauma Center in a metropolitan city of 3.7 million people. The hospital has ranked as the #5 Trauma Orthopedic Specialty Unit in the United States for eight years. At this point during orientation, you are permitted to care for one stable client per 12-hour shift. Today you start your shift with Ryan; a 25-year-old admitted through the Emergency Room after a motor vehicle accident with rollover resulting in a fractured right femur, multiple rib fractures, sternal bruises, and multiple abrasions. He is two hours post-op from an open reduction internal fixation of the right femur and appears alert and oriented. When you enter the room his first statement is, “Can someone please get me a cigarette or a patch; I have not had a smoke since yesterday morning!”

Assessment Data:

• The client is sitting up in bed with thigh-high anti-embolism stockings on the left leg only.
• Dressings to multiple abrasions appear dry.
• Urine in Foley Bag amber colored and urinary output in the past 2 hours 40cc
• Pain reported as 8 on a scale of 10 with a goal of 5

Vital signs:

• BP 130/80
• Heart Rate 92
• O2 Sats 94% on 4L Nasal Cannula

Blood Gases:

• pH 7.32
• PaCO2 53 mmHg
• HCO3 22mmol/L
• Pao2 84mm Hg

Physician’s Orders:

• Bed Rest Only
• Clear Liquid Diet
• Oxygen to maintain Spo2 of 92% or greater
• ABGs repeated every 4 hours
• Discontinue PCA and consult pain management
• Administer tetanus and flu immunizations before discharge
• Administer 1-2mg Morphine IV every 4-6 hours as needed for breakthrough pain

As you review the assessment data and physician orders, you plan client care and determine six nursing interventions you believe are appropriate and should be completed in this order within the next hour:

1. Administer 2mg Morphine IV now for breakthrough pain
2. Apply anti-emoblism stockings bilaterally
3. Call the physician to get an order for Nicotine Patch and report decreased urinary output with amber urine
4. Input consult for pain management into the electronic order system
5. Decrease O2 to 2L Nasal Cannula and continue Sp02 monitoring
6. Administer tetanus immunization

Instructions

As you write down the proposed interventions, the nurse manager stops by to check on your progress and asks you a few questions regarding your decisions. The nurse manager is disappointed and states, “One of these actions is not correct I want you to write down what you believe is the best choice from your list to do immediately and the action you believe is incorrect and should not be done. I will be back in 10 minutes to discuss your thoughts.”

On a document provide detailed responses to these questions:

• What is the best action to perform first from the six actions identified as part of planned client care for this particular client?
• What is the best action to perform second from the six actions identified as part of planned client care for this particular client?
• What is the best action to perform third from the six actions identified as part of planned client care for this particular client?
• What is the best action to perform fourth from the six actions identified as part of planned client care for this particular client?
• What is the incorrect action?