Scenario Summary
Virginia Henderson is a 46-year-old female who was admitted to the hospital one day ago with an exacerbation of her asthma and bronchitis. She has a history of rheumatoid arthritis, which was diagnosed when she was 35 years old. Joe Miller is the registered nurse who is assigned to care for Mrs. Henderson during this shift. Dr. Rowling has ordered bronchodilators for the asthma and antibiotics to treat her bronchitis. He also continued her home medications, Prednisone 5 mg BID (glucocorticoid), Humira (biologic response modifier), Hydrocodone 10 mg every 6 to 8 hours as needed for pain, Calcium 800 mg once daily, and Vitamin D 800 mg once daily.
The nurse from the night shift reported that Mrs. Henderson slept well all night although she awakened a few times with coughing and shortness of breath. The nurse noted the following when she performed her assessment at 04:00 a.m.: Oriented X 4, inspiratory wheezing with scattered ronchi, regular heart rate and rhythm, S1S2 with no abnormal sounds noted. Oxygen saturation level of 95% on oxygen at 2 liters/minute via nasal cannula. Abdomen soft with bowel sounds positive in all four quadrants. Moves all extremities against resistance with equal strength at 2+. Joints in hands and knees appear swollen. Last pain medication was administered at 09:00 p.m. the previous night. Vital signs were: B/P 148/84, P 92, R 24, T 99.6 °F at 07:20 a.m.
Your Role/Assignment
The student will occupy the role of the nurse, Joe, working on the medical-surgical nursing unit. As the nurse, the student will make key decisions related to which health history questions to ask, the physical assessments to perform, and the significance of the results of the health history and physical assessments findings to the patient’s overall health. The student will report to the physician. The student will also develop an educational plan to address one of the patient’s problems.
Key Players
• Joseph Miller, RN
• Virginia Henderson, patient
• Dr. Benjamin Rowling
Activity
Joe, RN: Good morning, Mrs. Henderson! My name is Joe, and I am the registered nurse who is caring for you today. Samantha is the nursing assistant who will help you with your personal care needs and will check your vital signs. How are you feeling this morning?
Mrs. Henderson, patient: I’m not feeling so good. My breathing is better, but I’m having a lot of pain.
Joe: Can you rate your pain on a 0-10 scale with 0 being no pain and 10 being the worst pain you’ve ever experienced?
Mrs. Henderson: It is a 7.
Joe: Where are you hurting?
Mrs. Henderson: My hands and knees are where it hurts the most.
Joe: Is there anything that makes it worse or better?
Mrs. Henderson: It is usually worse in the morning when I first get up. I have a hard time moving in the morning because of the pain and stiffness in my joints. Moving around, taking my pain medication, and getting into a warm bath are the things that help the most.
Decision Point 1
What action should Joe take at this time?
Option A
Obtain the ordered pain medication and administer it
Option B
Continue with the rest of the physical assessment
Option A
Joe: Mrs. Henderson, I have your ordered pain medication. It looks like your last dose was last night around 9:00 p.m. before you went to bed. I will ask Samantha to wait until your pain has decreased before coming in to do your bath this morning. I will also ask Harry, your physical therapist, to wait until a little later after Samantha has a chance to help you with your bath this morning.
Mrs. Henderson (thinking): Thank goodness! I can’t move without something to help with the pain.
Joe (Thinking): I hope her pain is relieved by the medication because she is in a lot of pain at a 7 on the pain scale.
Now that you’ve had your pain medication, I am going to proceed with the rest of your physical assessment. You sound a little hoarse this morning. Is your throat sore?
Mrs. Henderson: Yes, I’ve been coughing a lot.
Joe: Are you coughing anything up?
Mrs. Henderson: Yes, I’ve been coughing up some yellow-looking stuff.
Joe: Is it a lot or a little? How thick is it?
Mrs. Henderson: It’s only a small amount of really thick, yellow stuff.
Joe: I’ve gotten your morning vital signs from Samantha, and it looks like your blood pressure is a little high and you are running a temperature. Everything else looks normal. I’m going to do the rest of your assessment now.
Alert and oriented X 4. Heart rate regular, S1S2. No abnormal or extra heart sounds noted. Capillary refill < 3 seconds. Skin warm, dry, and intact. Peripheral pulses 2+. Lung sounds diminished with inspiratory wheezing. No accessory muscle use. Abdomen soft with hypoactive bowel sounds in all quadrants. Last bowel movement was 3 days ago. Moves all extremities with equal strength against resistance.
Joe: Have you noticed any changes in the amount of swelling, redness, or pain in your joints?
Mrs. Henderson: No, they look and feel the same to me.
Bouchard’s nodes noted in hands. Metatarsal joints red and swollen. Knee joint also appears swollen. Active range of motion in bilateral hands and knees reduced with patient reporting stiffness and pain. Option B
Joe: I’m going to finish up with my assessment and then I will check if you can have some pain medication. The night shift nurse told me you woke up several times coughing last night. You sound hoarse. Is your throat sore?
Mrs. Henderson: Yes, it is a little sore this morning, but my pain is what is bothering me the most.
Joe (thinking): She seems more concerned about getting pain medication than her breathing problems.
Mrs. Henderson (thinking): Why isn’t he listening to me? It hurts so much to move right now.
Joe: I’m going to have you sit up now so I can listen to your heart and lungs. Your lungs sound congested still. You mentioned that your throat was sore, and I know you’ve been coughing. Are you getting anything up when you cough?
Mrs. Henderson: It’s only a small amount of really thick, yellow stuff.
Joe: I’ve gotten your morning vital signs from Samantha, and it looks like your blood pressure is a little high and you are running a temperature. Everything else looks normal. I’m going to do the rest of your assessment now.
Alert and oriented X 4. Heart rate regular, S1S2. No abnormal or extra heart sounds noted. Capillary refill < 3 seconds. Skin warm, dry, and intact. Peripheral pulses 2+. Lung sounds diminished with inspiratory wheezing. No accessory muscle use. Abdomen soft with hypoactive bowel sounds in all quadrants. Last bowel movement was 3 days ago. Moves all extremities with equal strength against resistance.
The physical assessment shows: Alert and oriented X 4. Heart rate regular, S1S2. No abnormal or extra heart sounds noted. Capillary refill < 3 seconds. Skin warm, dry, and intact. Peripheral pulses 2+. Lung sounds diminished with inspiratory wheezing. No accessory muscle use. Abdomen soft with hypoactive bowel sounds in all quadrants. Last bowel movement was 3 days ago.
Joe: Have you noticed any changes in the amount of swelling, redness, or pain in your joints?
Mrs. Henderson: No, they look and feel the same to me.
Moves all extremities with equal strength against resistance. Bouchard’s nodes noted in hands. Metatarsal joints red and swollen bilaterally. Knee joint also appears swollen. Active range of motion in bilateral hands and knees reduced with patient reporting stiffness and pain.
Decision Point 2
Based on the assessment findings, what should Joe report to Dr. Rowling?
Option A
Joe should report the productive cough, breath sounds, bowel sounds with last bowel movement 3 days ago, Bouchard’s nodes, bilateral metatarsal and knee joints red and swollen, and joint stiffness and pain with reduced range of motion.
Option 2
Joe should report the patient’s pain level, productive cough, breath sounds, hypertension, temperature, and bowel sounds with a last bowel movement 3 days ago. Decision Point 3
What information should Joe include in developing a teaching plan for Mrs. Henderson about constipation?
Option A
Increased intake of fluids
High-fiber diet
Use of laxatives
Cultural influences
Option 3
Increased intake of fluids
High-fiber diet
Side effects of medication
Effects of limited mobility
Option A
Dr. Rowling (thinking): Why is Joe telling me about the Bouchard’s nodes and the bilateral metatarsal and knee joints being red and swollen when these would be expected with rheumatoid arthritis? I need to focus on her breathing right now.
Dr. Rowling: Joe, thanks for calling me with this information. I want to order medication to treat her cough and congestion and a breathing treatment for the wheezing. Please make sure she is drinking plenty of fluids and monitor her intake and output. I’ll come see Mrs. Henderson in just a few minutes.
Joe: Mrs. Henderson, I called Dr. Rowling, and he has ordered a breathing treatment for you and some medication to help with your cough and congestion.
Mrs. Henderson: Thanks, Joe. I appreciate it. It was getting harder to breath. I am pretty tired after so much coughing.
Joe: I’m going to reassess your lungs now that you’ve had your breathing treatment. Your lungs are sounding much better. I am not hearing any wheezing right now. Does your breathing seem easier to you?
Mrs. Henderson: Yes, much better.
Joe: What would you rate your pain level at now?
Mrs. Henderson: My pain level is about a 3, which I can tolerate.
Joe: I wanted to follow up on something now that your breathing is better. How often do you normally have a bowel movement?
Mrs. Henderson: I usually have one every 4 to 5 days, but I have to take a laxative or something to get my bowels going sometimes. I had a bowel movement 3 days ago.
Joe: I am going to assess your abdomen again as well.
Abdominal assessment findings are: Abdomen soft, slightly distended with hypoactive bowel sounds. Patient reports discomfort with light palpation of left lower quadrant. No bruit or friction rub noted. Option A
Dr. Rowling: Joe, thanks for calling me with this information. I want to order medication to treat her cough and congestion and a breathing treatment for the wheezing. Please make sure she is drinking plenty of fluids and monitor her intake and output. I’ll come see Mrs. Henderson in just a few minutes.
Joe: Mrs. Henderson, I called Dr. Rowling, and he has ordered a breathing treatment for you and some medication to help with your cough and congestion.
Mrs. Henderson: Thanks, Joe. I appreciate it. It was getting harder to breath. I am pretty tired after so much coughing.
Joe: I’m going to reassess your lungs now that you’ve had your breathing treatment. Your lungs are sounding much better. I am not hearing any wheezing right now. Does your breathing seem easier to you?
Mrs. Henderson: Yes, much better.
Joe: What would you rate your pain level at now?
Mrs. Henderson: My pain level is about a 3, which I can tolerate.
Joe: I wanted to follow up on something now that your breathing is better. How often do you normally have a bowel movement?
Mrs. Henderson: I usually have one every 4 to 5 days, but I have to take a laxative or something to get my bowels going sometimes. I had a bowel movement 3 days ago.
Joe: I am going to assess your abdomen again as well.
Abdominal assessment findings are: Abdomen soft, slightly distended with hypoactive bowel sounds. Patient reports discomfort with light palpation of left lower quadrant. No bruit or friction rub noted. Option A
Joe missed some important clues that should have focused his assessment. He should have treated her pain earlier, before moving on with the rest of the physical assessment. He also should have focused his assessment on her respiratory system next. The education for constipation should have focused on the increased intake of fluids and fiber, side effects of her medications, and the effects of her limited mobility. However, Mrs. Henderson received appropriate treatment with the hard work of everyone on the healthcare team. She was discharged home from the hospital 3 days later. Option A
Joe has performed appropriate focused assessments and has communicated with the rest of the healthcare team to make sure that Mrs. Henderson received all the care required to treat her medical conditions. Joe also provided education that was individualized to the patient’s problem of constipation. She was discharged home from the hospital 2 days later.
Questions
• Discuss how you decided what action to take next.
• Did you use a specific strategy to determine which health history questions to ask or physical assessment techniques to perform?
• Discuss any surprises or “Ah Hah!” moments you experienced during this exercise.
• Discuss how your decisions affected the safety of your patient. What would you do differently or the same?
• How will you use the information you learned from this exercise in your nursing practice?
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