Reference no: EM133694593
Assignment:
Situation - You are evaluating a patient in the ED that lives on the outer reaches of the suburbs on about 3 acres of land that walks into the ED and tells you that she thinks she was bitten by a snake.
Background - Maddy explains that she went to put the trash in the garbage cans that are behind a large boxwood cultivated to hide the cans. She was barefoot and did not have a flashlight, however, the moon was bright, and she said, "I knew where I was going". Suddenly, she felt intense pain which was described as, "if I stepped on a wasp nest." She saw nothing and heard nothing - just pain and burning. She thought about it for a minute and realized that wasp nests are usually high and not on the ground. She then realized it must have been a snake. As Maddy left her house for the emergency room she heard the dog and recognized the bark - he was killing the snake as he had done this in the past. Her neighbor just happened to hear the commotion and noise of the dog and came out to see what was going on. Maddy called out to the neighbor to make sure her dog was alright and quickly told him that she was on her way to the emergency room because she thought she had been bitten by a snake. In fact, the neighbor brought the dead copperhead to the emergency room. On assessment four different sets of fang marks were noted on the dorsal surface of her foot.
Assessment - While in the emergency room she remained calm even though her foot was throbbing, and it seemed to be swelling before her eyes. The swelling continued. Maddy described having a new set of black marks placed on her ever-increasing leg every 15 minutes. She is awake, alert, and oriented. Lungs are clear. Pulse is strong and regular. The swelling progressed upward to "about halfway up my thigh." Her vital signs are as follows: BP 110/70 (83), HR - 75, RR - 14, T - 99° F (37.2° C).
Points to assess: Is this Acute or Chronic? Is the patient Unstable or Stable? Is this Urgent or Nonurgent?
Recommendation(s) -
What are the risk factors for this patient, and do they contribute to the current primary problem?
What assessment(s) (expected finding) should be your focus? (Hint: Identify the relevant information first to determine what is most important.)? What signs and symptoms are commonly seen with this condition?
What data should you analyze (laboratory and diagnostic procedures) and report to the health care provider? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.)? What lab values may be abnormal?
What would your plan (nursing care) and recommendation(s) be to the health care provider? (Hint: Consider all possibilities and determine their urgency and risk for this client.)
What intervention(s) (therapeutic procedures and/or medications) would be your priority with this patient? (Hint: Determine the desired outcome first to decide which interventions are appropriate and those that should be avoided.)?Which intervention would be best for this patient?
What data/clinical information would you evaluate to support the plan to improve the patient's outcome? (Hint: Think about signs that would indicate an improvement, decline, or unchanged client condition.)?What changes to the patient's condition would I expect to see happen or have happened?
What type of treatment would Maddy receive?
What type of snakes are poisonous in Florida?
What are the different grades of pit vipers?
What are the characteristics of a poisonous snake?
What other type of creature can bite and cause tissue damage?
What are some ways to prevent or reduce the risk of getting bitten by a snake?
What are some ways to prevent or reduce the risk of getting an arthropod bite?
What are some of the ways to prevent getting stung?
What nursing interventions will you initiate based on this priority and what are desired outcomes?