John Taylor is a 68-year-old A

John Taylor is a 68-year-old African American male with ahistory of type II diabetes, coronary artery disease andhypertension. He came to the emergency department (ED) triagewindow because he felt crummy, complaining of a headache, runnynose, feeling weaker, “achy all over” and hot to the touch andsweaty the past two days. When he woke up this morning, he nolonger felt hot but began to develop a persistent “nagging cough”that continued to get worse throughout the day. John is visiblyanxious and asks, “Do I have that killer virus that I hear about onthe news?”

John lives in a large inner-city thathas had over three thousand confirmed cases of COVID-19. He hasbeen married to Maxine, his wife of 45 years, and is a retiredpolice officer and active in his local church.

The patient is in theTriage Area:

What data from the present problemand social history do you NOTICE as RELEVANT and why is itclinically significant?

RELEVANT History of Present ProblemData and its clinical significance?

RELEVANT Data from Social History and its clinicalsignificance?

Whatadditional clarifying questions do the triage nurse need to askJohn to determine his risk for COVID-19?

Whattype of isolation precautions does the nurse need to implement ifCOVID-19 is suspected? What specific measures must be implementedto prevent transmission?

Type ofIsolation, Rationale, and Implementation Components?

Emergency Department:

Mr. Taylor is brought into one of therooms in the emergency department. The nurse collects the followinginformation:

WhatVS data are RELEVANT and must be NOTICED as clinically significantby the nurse?

RELEVANTVital Sign and Pain Assessment Data:?

ClinicalSignificance and Relationship to Past Medical History and CurrentSituation:?

The nurse performs a FOCUSEDassessment. (perform the most critical assessments)

Nursing AssessmentFindings

• General Survey: Appears anxious, bodytense

• Neurological: Alert & oriented toperson, place, time, and situation. Generalized weakness.

• Respiratory: Breath sounds fine drycrackles bilat. with diminished aeration on inspiration andexpiration in all lobes anteriorly, posteriorly, and laterally,non-labored respiratory effort, episodic nonproductive cough.

• Cardiac: S1 and S2 audible, rhythmregular. No edema.

• Integumentary: Skin hot, dry, intact.Color appropriate for ethnicity

What assessment data is RELEVANT and must be NOTICEDas clinically significant by the nurse?

Collaborative Care: MedicalManagement

The emergency department physicianassesses Mr. Taylor and orders the following:

State the rationale andexpected outcomes for the medical plan of care?

Contact-Airborne-Droplet precautions: rationale and the expectedoutcome

Influenza swab: rationale and the expected outcome

COVID-19 swab (only if influenza negative): rationale and theexpected outcome

Chest x-ray: rationale and the expected outcome

Complete Blood Count (CBC): rationale and the expectedoutcome

Metabolic Panel (BMP): rationale and the expected outcome

Serum Lactate: rationale and the expected outcome

Oxygen per nasal cannula. Titrate to keep SaO2 92% or better:rationale and expected outcome

What diagnostic testingresults data is RELEVANT and must be NOTICED as clinicallysignificant by the nurse?

What lab results are RELEVANTand must be NOTICED as clinically significant by thenurse?

Prioritization oforders:       Rationale:

The physician tells Mr. Taylor thathis COVID-19 test was positive and that he will be admitted to thehospital.

What is the patientlikely experiencing/feeling right now in this situation? What canyou do to engage yourself with this patient’s experience, and showthat he/she matters to you as a person?

The Emergency DepartmentNurse must give report to the nurse on the medical floor who willbe receiving Mr. Taylor. Use the SBAR (Communication form todocument the nurse-to-nurse report

S(situation)

B(background)

A(assessment)

R(recommendation)

The patient is transferred to themedical-surgical floor of the hospital. You are the nurse on thefloor who settles the patient in bed in a negative air flow roomand obtains the health history and performs a physical assessment.The health history is listed in the “History of Present Problem.”The patient denies any surgeries in the past. He said that he had aflu shot this season and a pneumonia vaccine when he turned 65.

Home Medications

Metformin 1,000 mg PO daily

Amlodipine 10 mg PO daily

Atenolol 50 mg PO daily

Physical Assessment

• General Survey: Appears Anxious, body is tense.

• Head Face, Neck: Head is round, face symmetrical, neck range ofmotion intact, no swelling.

• Eyes, Ears, Nose, Throat: eyes symmetrical, scleral white,conjunctiva is pink, teeth white, lips, tongue and oral mucousmembranes are dry, hearing intact

• Neurological: Alert & oriented to person, place, time andsituation. Generalized weakness

• Respiratory: Breath sounds fine dry crackles bilat. withdiminished aeration on inspiration and expiration in all lobesanteriorly, posteriorly, and laterally, non-labored respiratoryeffort, episodic nonproductive cough.

• Cardiac: S1 and S2 audible, rhythm regular. No edema.

• Peripheral Vascular: Radial pulses strong and equal, skin ofupper extremities is warm, and color is appropriate for ethnicity,capillary refill of is less than 3 sections on fingers. Pedalpulses are not palpable, skin over lower legs and feet is pale andslightly cool to touch. Capillary refill on toes is 5 seconds.

• Integumentary: Skin hot, dry and intact. Skin turgor is brisk.Color is appropriate for ethnicity.

• Braden Scale:

  • Sensory perception no deficit

  • Moisture no problem

  • Activity ambulates

  • Nutrition potential problem

  • Friction and shear no problem

• Musculoskeletal: Upper and lower extremities and are strongweak, with full range of motion.

• Morse Fall Scale

  • No history of falling

  • Secondary diagnosis: yes

  • Ambulatory aid: none

  • IV: saline lock

  • Gait/Transferring: independent

  • Mental status: intact

• GI: Abdomen is round and soft with bowel sounds in all 4quadrants. Last BM was yesterday, soft brown stool.

• GU: Voiding without difficulty, urine clear amber. Last void wasthis morning at 0500.

• Mental Health: Behavior is appropriate for the situation.Anxious. He is retired.

• Intervention (lines, drains, etc.): IV: saline lock leftforearm, site clean and dry, dressing dry and intact.

• Wounds/Incisions/Ostomies: None

Based on Mr. Taylor’s age and past medical history, he is atrisk for developing complications that could lead to severeillness.

How will you monitor for early signs that his healthstatus is deteriorating and he is experiencing complications of thevirus COVID-19? What do these signs indicate?

Change in condition: andClinical Significance: