All Virtual clinical scenarios, Med-Surg & Room, all Evaluated

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All Virtual clinical scenarios, Med-Surg & Room, all Evaluated All Virtual clinical scenarios, Med-Surg & Room, all Evaluated Linda Yu 1Assess vital signs and urinary output. 1 r 2Start a seconda... ry IV line, 20 gauge cath with normal saline TKO (blood tubing). 3 t 3Have a second licensed nurse sign & verify the correct identification on the blood 2 request and blood unit. 4Take vital signs and start administration of blood. 4 5Assess patient and vital signs Q5 for first 15 minutes, and be prepared to stop blood 5 immediately if patient experiences increased temp, hematuria, or anxiety. Marcella como Explanat ion 1 1Use therapeutic communication/Active Listening Using therapeutic communication to a psychological condition. 2 2Full Assessment Full assessment is first step of establish condition. 3 3Provide emotional support After proper assessment, provide prop 4 4Documentation Document patient baseline assessment Your order Correct order Step Ex 1 1 Use therapeutic communication/Active Listening Therapeutic Communication Assessment request/concerns. 2 2 Educate patient Feeling of being "dirty" is common for rap 4 3 Provide supplies and needed instructions. Demonstrates care for the patient. Patient surroundings. 3 4 Offer to Assist After receiving supplies and instructions p needed. Also, interaction could diminish f untouchability. Your order Correct order Step 1 1 Use therapeutic communication/Active Listening Listening to v 2 2 Ask open-ended questions Allows more 3 3 Seek clarification Narrows dow 4 4 Summarize discussion States main 1 Restate or paraphrase patient Conveys listening & understanding of messag 2 statements 2 Acknowledge patient's decision Gives acceptance to wishes of patient after re 1 3 Review plan of action Marks beginning of next phase of POC. 3 4 Notify social services Notifying social services is next step of plan o 4 5 Document process Accurate documentation is to be performed a 5 1 Review Labs Negative/positive test results will dictate Edu 1 2 Educate Patient-STD's and pregnancy Education is achievable after understanding p 2 3 Provide emotional support Nurse is to act as patient advocate and suppo 3 4 Discuss Support Groups Secondary issue designed to help victims wit 4 Jose Martinez Room 304 Jose Martinez, Jose Martinez, 43- year old male experiencing chest pain while watching a state rival football game earlier in the evening. Chest pain became progressively worse, so he called for an ambulance to bring him to the Emergency Department. Once the ambulance arrived, he reported his pain as 10/10. The 12-lead EKG showed ST elevation. Vital signs were HR 160, BP 145/102, Respirations 23, and Pulse Ox 89%. He was given nitroglycerin during transport to the hospital with little relief. He complained of feeling “light- headed”. He has been admitted to the unit, and the pain has subsided. He does have a 10-year history of hypertension. He was transferred here to the cardiac stepdown unit from the ER, because no beds were open in cardiac ICU. Ambulance report: Nitroglycerin SL x 3, 12-lead EKG, Blood drawn for cardiac enzymes, Peripheral IV started to left forearm. You responded correctly to 4 out of 6 evaluations: Category Your response Explanation Educational Needs Increased acuity Mr. Martinez needs further understanding of why he is having chest pains an Fall Risk Increased acuity Due to Mr. Martinez feeling “light -headed”. Health change Increased acuity Due to the risk of cardiac injury, possible vessel blockage, and history of hyp injury. Neurological Normal acuity No evidence of deficits in the report. Pain level Increased acuity Patient states the pain has subsided. Psychological Needs Normal acuity Mr. Martinez states he is anxious. Description Your Response Explan Acute Pain True Angina (chest pain) is the pain associated with dec Altered body image False Scenario does not support this. Anxiety True Patient expresses he is experiencing anxiety. Disturbed thought process False Scenario does not support this. Impaired gas exchange False Oxygen saturation is 89%. Impaired tissue perfusion True Due to altered cardiac blood flow circulation. Ineffective health maintenance True High blood pressure, high cholesterol, and high trig Powerlessness False This is related to acute illness and inability to contr knowledge regarding medical conditions. Risk for decreased cardiac output False Scenario does not support this diagnosis as the pat output. Safety Your Description Response Explan Drug therapy True Monitor patients for antithrombotic therapy due Risk for social isolation False Scenario does not support this. Your order Correct order Step Explanation 1 1 Assess airway, breathing, circulation. Assessment is always the first step in the nursing process. 4 2 Ensure continuous EKG Analysis of the EKG is essential to monitoring. ensure appropriate patient care management. 3 3 Administer oxygen therapy to Myocardial oxygen demand is make sure oxygen saturation is increased during an acute event. greater than 90%. 2 4 Provide Morphine Sulfate IVP as Pain relief helps increase the prescribed. oxygen supply and decrease myocardial oxygen demand. 5 5 Reassess patient’s vital signs After proper treatment, reassess and pain level. patient’s response to interventions. 1Assess for the abrupt 1 cessation of pain Indicates that the clot has been dissolved. 2Initiate IV Heparin. Large amounts of thrombin are released increasing the risk 3 for vessel-reocclusion. 3Give ASA. Maintain the patency of the coronary artery after 4 percutaneous coronary intervention. 4Observe for bleeding. During thrombolytic administration immediately report any 5 indications of bleeding to the Healthcare Provider. 5Monitor aPTT Used for evaluation of Heparin therapy. 2 1 1Provide emotional support. Needed to promote a positive learning environment. Allow patients to verbalize and express feelings of fear, anxiety, anger, denial, and grief. 2Assess Mr. Martinez’s 2 willingness to learn. 3Provide introductory 3 information on prescribed antithrombotic medication. Assessment of Mr. Martinez’s willingness to learn to know how much information should be taught at this time. Be specific in education efforts to promote understanding and compliance. 4Report Mr. Martinez’s 4 emotional distress to Case Management. Case Management will identify need for interdisciplinary intervention. 5Document all findings. Documentation is necessary to validate education 5 was provided and understood. Any conversations with an interdisciplinary team are to be documented in the medical record. Your order Correct order Step Explanation 3 1 Troponin 1.0 mg/mL. 4 2 CPK: 360 mcg/mL. Troponin is a sensitive marker for myocardial damage. It may indicate heart damage, but could also be elevated as a result of increased strenuous activity or damage to other parts of the body. 5 3 CK-MB6.8 A marker, but not specific for acute MI. 1 4 Serum Potassium 4.2 mEq/L. Abnormal Potassium Lab values can affect cardiac conduction. 2 5 Serum Sodium Serum-Sodium level is normal with lesser adverse 142 mEq/L. cardiac events on cardiac conduction. Your Correc orde r t order Step Explanation 4 1 Clarify with Mrs. Martinez that she is asking if it is okay to resume sexual relations with her husband upon discharge. 2 2 Promote open communication Therapeutic communication involves open discussion and understanding of what the other person is attempting to communicate. Open communication after a between Mr. and Mrs. Martinez. myocardial infarction is needed for the patient and family to promote positive coping. 1 3 Explain to Mr. and Mrs. Martinez the disease process following a myocardial infarction. 3 4 Discuss physical limitations following a myocardial infarction. It is important to explain the disease process in layman’s terms to the patient and family to promote understanding of how this may affect their sexual relationship. Explains to the patient and his wife that sexual relationships may resume when he can walk one block or climb 2 flights of stairs without symptoms. 5 5 Provide information to Mr. and Support groups can be beneficial for Your Correc orde r t order Step Explanation Mrs. Martinez regarding support groups. Karen Cole patients and families with similar health care concerns. 56 year old female, Karen Cole, a school principal at White House High School. Admitted directly from the Dr.’s office to the IMCU after initial complaint for tightness in her chest, denies pain, and slight shortness of breath. Vital signs are BP: 168/92, P: 90, R: 24, T: 98.6 F, 37 C. Her husband insisted that she come. She is insisting that she will only stay 12 hours, because she has to be back to school in the morning. You correctly diagnosed 5 out of 8 options: Physiological Description Your Response Acute Pain True Patient denies pain. Impaired coping False Patient in denial of po Nausea False No indication at this t Risk for impaired comfort True Tightness in chest. Safety Description Your Response Fall, for Risk True No indicat Infection risk False No indicat Risk for constipation False Not at thi Risk for injury True Possible m 1Apply O2 at 2 L nasal-cannula. Patient complains of slight shortness of 3 breath. 2Connect patient to cardiac monitor, Patient presents with signs/symptoms of a 2 assess vital signs. possible cardiac event. 3Complete full assessment. Health history and physical assessment is 4 required for baseline data. 4Obtain IV access and draw initial 5 labs. 5Orient patient and husband to the 1 unit. Admission labs are necessary and access for potential IV medications. Orient patient and spouse to reduce stress and promote safety. 4 1Notify Cath Lab for stat cardiac cath. Assure readiness for procedure. 2Obtain informed consent for cardiac 3 cath. Consent must be obtained before Morphine is administered. 3Give IV morphine, 2mg IVP. Decrease patients pain/anxiety. 1 4Reassess vital signs and chest pain. Ensure patient is stable before patient is 2 transferred. 5Transport patient to Cath lab with 5 Cardiac monitors. Maintain patients safety and health during transport. Your order Correct order Step Explanation 2 1 Take vital signs. Assess patient for baseline stability. 3 2 Post-op assessment. Re-assess patients pain and cath site for potential bleeding. 4 3 Ensure pressure dressing is in place. Prevent bleeding by assuring dressing is in place 1 4 Instruct patient to lie in supine position for 6 hours. To keep the pressure dressing in place. 5 5 Assess pain and cardiac rhythm Q 15 minutes. Dysrhythmias can occur after catheterization. 1Explain the necessary procedure. Explain that patient may experience some 2 discomfort. 2Perform hand hygiene and don 1 gloves. Protection for patient and staff from blood-born pathogens. 3Remove infiltrated IV. Stop potential tissue damage. 3 4Don new gloves. Initial gloves are now contaminated. 4 5Insert new IV above prior site or 5 opposite limb. Starting IV below infiltrated site may cause further tissue damage. Your Correc order t order Step Explanation 1 1 Assess patient and families readiness to learn. Learning assessment needs to be done prior to education. 3 2 Provide patient post MI Ensure patient understands lifestyle education. changes and need for monitoring antithrombotic therapy. 2 3 Patient and family should Nurse’s responsibility includes patient verbalize understanding of and family understands discharge discharge instructions. instructions. 4 4 Schedule cardiac rehab. Required for patient to have an acceptable date/time to begin. 5 5 Document. Documentation provides accurate record that proper education was completed. TIM JOnes Description Your Response Decisional conflict False Scenario does not support this Defensive coping True Related to fear of abuse as a r Disturbed sleep pattern False Scenario does not support this Ineffective health maintenance False Patient is unable to protect hi Risk for post-traumatic stress syndrome True Patients with a history of abus Risk for spiritual distress True Scenario does not support this Safety Description Your Response Exp Isolation precautions False Scenario does not support this diagnosis. Risk for injury at home True Related to presenting with different stages Your orde r Correc t order Step Explanation 2 1 Wash hands. Hand washing is the best prevention to spreading disease. 1 2 Reassure patient that Due to patient guarded behavior, the nurse he is in a safe seeks to reassure the patient to provide comfort. Your orde r Correc t order Step Explanation environment. 3 3 interviewing patient Interviewing is part of the assessment process regarding need for and allows the nurse to establish rapport with hospitalization the patient and gives the patient the opportunity to explain the presence of injuries. 4 4 Complete physical Physical assessment provides the nurse with assessment. objective data. 5 5 Notify Charge Nurse If physical abuse or neglect is suspected, health and Social Services. care professionals are required to file a report with adult protective services. Your Correc order t order Step Explanation 1 1 Use therapeutic communication. 2 2 Seek clarification from Mr. Jones on why he does not want to leave the room. 3 3 Reassure Mr. Jones that he will Mr. Jones is guarded and this provides an opportunity for him to discuss what has caused his bruising. Clarification is part of the therapeutic communication milieu. Reassurance offers needed be safe during his hospital stay. Therapeutic communication for the patient 4 4 Administer prescribed anxiolytic medication prior to transfer to CT area. 5 5 Offer UAP to accompany Mr. Jones during the CT process. Anxiolytic therapy may assist with comfort and relief from anxiety. Having someone present with Mr. Jones reinforces the safe care environment. 1Assess Mr. Jones for 1 injuries. Assessment is always the first step of the nursing process. 2Assist Mr. Jones back After assessment and determining there are no reasons not 2 to bed. 3Provide personal 4 hygiene. 4Remind Mr. Jones to 3 seek assistance to move Mr. Jones, assist him back to bed. Urine or feces left on skin can lead to skin breakdown. Reorientation to call light and fall precautions reduces risk for injury. Ensure call light is within reach before leaving the before getting out of room – provides Mr. Jones with a means to communicate the bed. next time he needs assistance. 5Obtain a sitter to 5 stay with patient. 1Notify healthcare provider for 4 change in respiratory assessment. 2Administer nebulizer 1 treatment per HCP order. There is a significant change in respiratory status that needs to be addressed. Provide nebulizer treatment to assist opening up airways to ease breathing. 3Reassess respiratory status. After treatment with nebulizer, reassessment of the 3 lungs is needed to evaluate the effectiveness of the treatment. 4Encourage Mr. Jones to cough 2 and take deep breaths hourly. 5Document findings from 5 repeat assessment. Deep breathing and coughing will help Mr. Jones keep airways open. Documentation is necessary after providing care or reassessment. 1Talk with Mr. Jones about his 1 wishes for end of life. 2Call Mr. Jones’ children per his 4 request. 3Ask Mr. Jones if he would like for 3 a chaplain or minister to be called. 4Discuss options with Mr. Jones 2 regarding end of life care. 5Notify the Social Worker of need 5 for a new nursing home placement option. Talking with Mr. Jones ensures that his wishes for the end of life are clear, and that his DNR order will be followed. Having family members in attendance at the end of life can be comforting to the patient and the family. Offering spiritual services at the end of life can provide comfort to the patient. Mr. Jones suffered abuse at the nursing home and needs to be placed in a safer environment. The social worker is responsible for seeking alternative living arrangements for the patient. SARAH KATHY HORTON Description Your Response Explanation Acute Pain True Due to gunshot wound injury to shoulder and thigh. Anxiety True Ms. Horton has experienced a traumatic event and is being medicated for anxiety. Body Image Disturbance False Scenario does not support this diagnosis at this time. Disturbed personal identity False At this time Ms. Horton is a victim of a mass shooting. Fatigue False Scenario does not support this diagnosis at this time. Impaired Physical True Ms. Horton is allowed out of bed with assistance only Description Your Response Explanation Mobility due to a gunshot wound to the thigh. Impaired skin integrity True Due to gunshot wound injury to shoulder and thigh. Risk for decreased oxygenation False Scenario does not support this diagnosis at this time. Risk for post trauma syndrome True At this time Ms. Horton is a victim of a mass shooting. Safety Description Alteration of Protective Mechanisms Your Respons e Explanation True Ms. Horton is the victim of an external threat and therefore may perceive she cannot always. Your orde r Correc t order Step Explanation 1 1 Wash hands Hand washing is the best prevention to spreading prior to entering disease. the room. 3 2 Assess respiratory status by observation. 2 3 Do not disturb the patient. 4 4 Reduce stimuli in the patient room. 5 5 Documents all findings. Assessment is always the first step in the nursing process. Adequate rest is essential for healing and physical and mental functioning. If a patient is asleep and stable there is no need to wake them. At this time the patient is resting and not in distress. Decreasing all unnecessary stimuli will help the patient to rest. Documentation is necessary to demonstrate care was provided. Your orde r Correc t order Step Explanation 1 1 Wash hands prior Hand washing is the best prevention to spreading to entering the room. disease. Your orde r Correc t order Step Explanation 3 2 Assess Ms. Horton’s orientation. 4 3 Medicate patient. 2 4 Attempt de- escalation strategies. 5 5 Documents all findings. Assessment is always the first step in the nursing process. Be alert for patients who exhibit verbal aggressiveness as this can indicate confusion and/or elevated anxiety. Appropriate medication is provided to decrease physical pain. Creates a nonthreatening environment for the nurse and patient. Documentation is necessary to demonstrate care was provided. Your orde r Correc t order Step Explanation 1 1 Gather supplies needed for dressing change. Gather all supplies needed as this is a sterile procedure and the nurse should not have to leave the room once the dressing change is begun. 2 2 Wash hands upon Handwashing is the best prevention for decreasing entering the room. 3 3 Explain the procedure to Ms. Horton. the spread of infections. Nurses should always explain procedures to patients and answer any questions to ensure understanding and consent. 4 4 Provide Morphine Morphine Sulfate has been ordered to be given prior Sulfate 4 mg IV. 5 5 Perform dressing change. to the dressing change. It does not need to be given prior to consent and understanding noted by the patient. The dressing change is performed after the morphine has time to take effect to Your Correc orde r t order Step Explanation 2 1 Educate Ms. Horton that paroxetine (Paxil) is to be taken as ordered. 1 2 Reinforce past coping mechanisms that have been effective. Paroxetine has been found to be effective in the treatment of PTSD and may take one to four weeks for full effectiveness. Effective coping mechanisms are essential for survivors to adapt to their new surrounding and routines. Your Correc orde r t order Step Explanation 3 3 Educate family regarding active listening and open communication. 4 4 Educate the family regarding intervention and support for Ms. Horton. 5 5 Documents all interactions. Survivors benefit from talking about their experiences which provides clarity and helps them begin to problem solve. Beyond active listening and open communication, communication among caregivers and families provides opportunity for a more stable home environment. Documentation is necessary to validate education was provided and understood. Your order Correct order Step Explanation 3 1 Assess Ms. Horton’s orientation status. Assessment is the first step in the nursing process, and anxiety can cause disorientation. 1 2 Use therapeutic Therapeutic communication is used to communication to re-orient reassure the patient during an anxiety and provide reassurance. producing event. 2 3 Assist Ms. Horton back into the Ms. Horton needs to be assessed for wheelchair. potential injuries. 4 4 Escort patient to the ER for a At this time, Ms. Horton needs to be physical and psychological assessed for potential injury, and evaluation. psychological distress. 5 5 Provide report to ER nurse. The nurse must provide information relevant to Ms. Horton’s situation. (SBAR). JOHN WIGGINS Description Your Respons e Explanation Acute pain True Headache. Deficient knowledge False Safety concerns from riding his ATV w/o helmet. Symptoms of worsening head-injury. Danger of ETOH dependence, and use when operating motor vehicles. Grieving False No evidence. Impaired mobility, risk True Potential for declining neurological status. Description for Your Respons e Explanation Nausea False Patient verbalized complaint of nausea. Safety Description Your Response Explanation Bleeding, risk for True Head injury may be slow subdural hematoma. Peripheral Neurovascular dysfunction False No evidence. LINDA PITTMON Description Your Response Explanation Anxiety False Not supported by the initial report . Disturbed body image False Presents with toes that are an abnormal color (black) . Disturbed sleep pattern False Scenario does not support this diagnosis. Impaired Memory False missing. Ineffective health maintenance True Patient is unable to properly care for her diabetes. Risk for malnutrition True related to homeless situation. Safety Description Your Response Explanation Impaired tissue integrity True Related to numbness of right foot and discoloration of toes. Isolation Precautions False No indication for isolation at this time. Risk for physical injury True Related to homeless situation. Risk for Urinary Retention False There is no indication of this issue. Self-care deficit True Related to uncontrolled diabetes. Your orde Correc r t order Step Explanation 1 1 Assist Anesthesia with their Glasgow coma scale <8 requires Your orde Correc r t order Step Explanation initial assessment and airway need for intubation because patient management. cannot maintain and protect their own airway. 4 2 Administer Valium 5mg IV push. To prevent further seizure activity. 3 3 Initiate a 2nd 18 gauge IV Standard of care for reducing Catheter and begin Mannitol intercranial pressure preoperatively, infusion. and requires a designated IV site. 5 4 Contact family and be present Patient is not able to consent for with Healthcare Provider as he surgery himself, and to further explains need for surgery to the reduce anxiety of family members. family. 2 5 Continue frequent vital signs and To continuously monitor deteriorating remain with patient - escort him to surgery. condition and assist Anesthesia with airway management during transport. Your Correc orde r t order Step Explanation 1 1 Wash hands and don gloves. 5 2 Obtain blood for laboratory testing Handwashing is the best way to prevent the spread of infection. Lab values are needed as a priority to obtain needed medical information. Blood cultures are and blood culture # drawn from 2 separate sights. 1. 2 3 Obtain blood from secondary site for blood culture #2. 4 4 Initiate IV fluids to peripheral site. 3 5 Administer levofloxacin as ordered. Blood cultures need to be drawn from 2 separate sites to ensure validity of the results. This increases the likelihood of detecting the presence of bacteria or fungi if they are present in the blood. This is needed to administer the IV antibiotics and have IV access for any other needed intravenous interventions. Antibiotics are given to the patient after cultures have been 1Ask the patient if she knows where 4 the syringe came from and what was in the syringe. The nurse needs to obtain additional assessment information about the syringe. 2Assess the vital signs and perform a This assessment is necessary to provide to 1 neurological focused assessment. the physician for further possible orders. 3Place the syringe in a biohazard bag 3 and place a patient identification label on bag. 4Notify the charge nurse and house 2 supervisor of the syringe found in bed. 5Notify the physician of assessment 5 findings and await further orders. Always follow institutional guidelines for security of evidence when a potential illegal activity has occurred. Always follow chain of command when a potential illegal activity has occurred. 1Assess vital signs and perform head to 1 toe assessment. 2Therapeutic communication with 3 patient. 3Call Healthcare Provider for change in 2 health status and receive orders for anxiety medication. 4Prescribed medication for anxiety must 4 be administered. 5Assess for therapeutic response to 5 medications. Assess vital signs and perform heads to toe assessment. Therapeutic communication reassure patient that she is being cared for in a safe environment. Healthcare provider should be called for medications to treat symptoms of withdrawal and anxiety. To ensure hip is still in proper alignment. To ensure patient’s symptoms are relieved. Your orde r Corre ct order Step Explanation 4 1 Ask Mrs. Pittmon if she remembers the conversation with the physician and if she has any further questions that need to be addressed. Patients should be fully informed of their procedure and have all questions asked prior to signing a consent. 3 2 Perform pre op checklist. This ensures that all components of the preoperative assessment including H and P, reports, etc. are available for the perioperative healthcare team. 5 3 Ensure signed consents are on the chart. 1 4 Ensure type and cross match for blood products is complete and results are in electronic medical record. This demonstrates that the requirements for informed consent have been satisfied. Consent is voluntary and freely given by the participant, guardian or legally authorized representative. For an amputation or any major invasive surgery, it may be necessary for the patient to receive blood. Having the type and cross match and results ensures Your orde r Corre ct order Step Explanation swift delivery of blood products if needed. 2 5 Have IV antibiotics available to administer when surgery calls for the patient to be transferred to pre op area. Antibiotics are often given within an hour of surgery time to decrease chance of post- operative infe 1Pre-medicate for pain with prescribed 4 medication. 2Don clean gloves to remove old 3 dressing. Dressing changes can be painful so providing pre-dressing change pain medication can decrease the pain during the procedure. The old dressing is removed with clean gloves as this is not a sterile procedure. 3Monitor neurovascular status assessing Assessment of the wound/stump should 2 skin color, temperature, sensation, pulses above amputation. 4Don 2nd set of clean gloves to provide 5 stump care. The wound has been sutured and is not an open wound/stump. 5Elevate stump and rewrap with a dry 1 clean dressing. always be completed and documented to ensure proper wound healing. Wrapping of a stump is a clean dressing change, not a sterile dressing change. The stump should be elevated when providing wound care and rewrapping to decrease edema around the base of the stump. 1Check for cognition A/O x4. Deterioration of cognition is the first sign of 1 increased intracranial pressure. 2Check pupils - equal and 2 reactive. 3Check nose and ears for 3 drainage. 4Check cranial nerves – smile, 4 tongue, shoulder shrug. Increased intracranial pressure can result in sluggish/dilated pupils on the effected side. CSF fluid drainage may be a sign of neuro trauma. Differentiates between global and focal injury. 5Assess extremity strength. Per head-to-toe assessment sequence. 5 1Explain to Mr. Wiggins why the pain 1 medicine must be held. Administering pain medication at this point could mask symptoms of worsening neurological condition. 2Inform patient that you will discuss 4 findings and pain medication with Healthcare Provider. 3Ask the patient to remain in bed, 2 and not get out of bed without assistance. 4Put side rails up and call light in 3 patients hand. Reassures patient that his pain control will be discussed with Provider. In order to promote safety in the presence of a declining neurological status to prevent injury from falls/seizure. To encourage patient compliance with falls- risk protocol. 5Notify Physician and document. Declining neuro status requires immediate 5 Provider attention. 1Contact radiology for a stat CT scan of 5 the head. 2Inform the patient of the plan of care/stat 1 CT, and administer Tylenol 1g. Stat orders must be implemented first to determine if there has been a change since his initial CT. In order to reduce anxiety and treat pain appropriately. 3Start a saline lock. Emergency access and need for CT 4 contrast. 4Inform patient why you are doing neuro To monitor for evidence of further 3 checks q30 minutes, and perform another deterioration. baseline neuro check. 5Inform the patient why he will not be 2 receiving lunch. 6Notify Charge nurse of deterioration of 6 patient. NPO status necessary in case of surgical intervention. To ensure available staff can cover other patients while you accompany patient to CT scan. 1Remain with the patient 1 and turn him on his left side. 2Call for help and initiate 3 Rapid Response Team. 3Note time when seizure 2 began and duration. Protect patient from injury. Additional assistance is needed for management of patient due to acute change. Duration of seizure is important to assess severity and have a baseline of seizure activity. 4Ensure IV access. IV access may have been dislodged during seizure 4 and is imperative for the treatment of severe seizures. 5Reassess vital signs and 5 neurological status postictal. Postictal phase patient is obtundent, and may not able be to be responsive to neurological assessment. Needed for d Your orde Correc r t order Step Explanation 1 1 Assist Anesthesia with their Glasgow coma scale <8 requires initial assessment and airway need for intubation because patient management. cannot maintain and protect their own airway. 4 2 Administer Valium 5mg IV push. To prevent further seizure activity. 3 3 Initiate a 2nd 18 gauge IV Standard of care for reducing Catheter and begin Mannitol intercranial pressure preoperatively, infusion. and requires a designated IV site. 5 4 Contact family and be present Patient is not able to consent for with Healthcare Provider as he surgery himself, and to further explains need for surgery to the reduce anxiety of family members. family. 2 5 Continue frequent vital signs and To continuously monitor deteriorating remain with patient - escort him to surgery. condition and assist Anesthesia with airway management during transport. Estelle hatcher: 1Introduce Yourself/Identify Introduction and identification are the first steps. 1 Patient 2Full Assessment Establishing baseline and identifying areas of concern will 2 order to educate patient. 3Educate Patient Helps patient understand circumstances of treatment con 3 4Evaluate Understanding Important to follow education up with evaluation for effect 5 5Provide Comfort Perform based on information attained from patient discus 4 1Wash/Glove Hands First step in patient assessment/intervention. 1 2Inspect Pain Location Assessment first step in Nursing Process. 3 3Check Proper Positioning Intervention is second step in Nursing Process. 2 4Verify Call Light/Bed Safety After patient care, always place call light in rea 4 precautions position. 5Notify Doctor (for possible Removal) 5 1Educate patient of 1 procedure Before performing procedure, inform patient. 2Evaluate Understanding Make sure patient understands information given. 2 3Remove NG-Tube After Education evaluation patient is ready for procedure. 3 4Administer Diet Order New clear liquid diet order can be started. 4 5Document Results Accurate documentation is to be performed after patient ca 5 BEFORE! 1Wash/Glove Hands First step in patient assessment/intervention. 1 2Full Assessment Assessment is first step in Nursing Process. 2 3Encourage Incentive Spirometry Increasing oxygen levels is a proper intervention. 3 4Verify Call Light/Bed Safety 4 precautions After patient care, always place call light in reach an 5Document Results Accurate documentation is to be performed after pat 5 NEVER BEFORE! 1 1Use therapeutic communication/Active Assessment is first using correct Therapeutic C Listening 2Educate Patient Planning/Intervention is second/third step in Nu 2 3Evaluate Understanding Performed after education. 3 4Verify Call Light/Bed Safety 4 precautions After patient care, always place call light in rea position. 5Document Results Accurate documentation is to be performed aft 5 performed, NEVER BEFORE! John Duncan Assess intake and 1 output and possible reasoning Assessment is needed to determine intake and 'Active listening' is important step to understanding patient condition/concerns. 2 Construct dietary consult (plan) Nurse, pati 3 together to 3 Acquire daily weight and food intake Monitoring 1 accurate in assist in ev 4 Evaluate outcome of dietary plan 4 1Full assessment including both Full assessment including orthostatic vital sign 1 lying/standing 2Check input/output for possible 2 dehydration 3Teach patient about safety when 3 getting out of bed immediate concern. Vomiting can cause dehydration. Educated patients are less likely to be injured. 4Document findings Accurate documentation is to be performed aft 4 performed, NEVER BEFORE! 1 Wash and glove hands First step in patient assessment/intervention. 1 2 Provide emesis basin/cloth Meets immediate need. 2 3 Vital assessment Routine orders are performed after main concerns 3 4 Administer antiemetic medication Medications can be given after assessment has bee 4 5 Evaluate medication effectiveness Evaluation should always be performed to check eff 5 medication. 1Vital assessment Because of patient weakness vital signs are perf 1 2Assessment of bowel movement Assessment of color, odor, consistency, and amo 2 3Administer protocol antidiarrheal 3 medication Follow protocol medication orders for patient's c 4Document results/findings Accurate documentation is to be performed afte 4 performed, NEVER BEFORE! 5Include patient condition change in 5 shift report 1Inform and educate spouse of 2 dietary orders Priority intervention. Addresses spouse's immediate involvement assures dietary compliance. 2Evaluate/modify plan of care Changes should be communicated in plan of care. 3 3Assess food consumption and 1 intake and output New dietary order should be evaluated for effective 4Document findings/results Accurate documentation is to be performed after pa 4 NEVER BEFORE! Ana rails Use therapeutic 1 communication/Active Listening 'Active listening' allows patient to express herself and is first step to understanding patient condition. 2 Educate patient regarding patient care Education is to be ac 2 understanding patie planning and implem 3 Evaluate patient learning Evaluation of goals f 3 achieved after patien 4 Place call light and check bed for 4 safety After patient care, al reach of patient and 5 Document results and findings Accurate documenta 5 after patient care is BEFORE! Your order Correct order Step Explanation 1Listen to patient 1 concerns 2Reassure patient of 2 options Patient assessment is the first step of nursing process Planning/Intervention follows patient assessment 3Notify lead nurse/doctor Doctor should be notified of patient's wishes for necessary a 3 4Contact Social Services Doctor must write order for Social Service Consult 4 5Document results Accurate documentation is to be performed after patient care 5 BEFORE! 1 1Wash and glove hands Wash and glove hands is the first step in patient assess 2Visual assessment Visually assess patient's respiration rate. Patient assess 2 the nursing process. 3Do not disturb Planning/Intervention follows patient assessment 3 4Verify Call Light/Bed Safety After patient care, be sure the call light is within reach 4 precautions is in the locked position. 5Document results Accurate documentation is to be performed after patien 5 NEVER BEFORE! 1 1Assess for bowel sounds Patient assessment is the first step of the nursin 2Encourage fluids/fiber/ambulation Planning/Intervention follows patient assessmen 2 3Evaluate patient understanding Evaluation can be achieved after patient educati 3 4Attain fluids/fiber diet and assisted 4 ambulation Can only be done after patient education/evalua 5Document results Accurate documentation is to be performed after 5 performed, NEVER BEFORE! 1. rape victom- marcella (9) 2. viola- second day post op hip repair (5) 3. tom-urinary stones (7) 4. Arthur- mva (2) 5. appendectomy- Richard (3) 6.john Duncan- gastroenteritis (8) 7.ann- back pain (10) 8. sarah- chronic. Renal failure (6) 9. virginia smith- mastectomy (4) 10. lithia munson- subdural hematoma (1) Arthur Thomason Room 301 Arthur Thomason, 56-year-old MVA victim, fourth day post op with a splenectomy and femur repair. He is experiencing new onset of shortness of breath and has a nasal cannula with 2L of Oxygen in place. He is restless with slight confusion but is easily orientated with attempts from nurse. Temperature spiked during the night to 102.4, BP now 146/94 which is slightly elevated, respirations at 30 bpm and slightly labored, heart rate 102 versus 84 from last night shift. Skin cool to touch and appears pale. His coughing, to clear his airway, appears ineffective. Recent chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes. Recent blood gases demonstrate falling PaO2 (hypoxemia) and increasing CO2 (Hypercapnia). Mr. Thomason is anxious and is obviously worsened from the shift before in overall condition. You responded correctly to 3 out of 6 evaluations: Category Your response Explanation Educational Needs Increased acuity Status assessment reports post op therapy (cough, turn deep br Health Change Increased acuity Status assessment reports recent major surgery and abnormal v LOC Normal acuity Status assessment reports slight confusion Pain Level Increased acuity Status assessment reports recent major surgery Psychological Needs Increased acuity Status assessment reports no indication of increased psychologi Safety Normal acuity Status assessment reports slight confusion Richard Dominec, A 47-year-old married father of three children has been admitted for an emergent appendectomy in the evening as soon as there is space available in the OR. He is currently febrile with temperature 100.8, HR 99, BP 135/96, RR 20, PaO2 96%, nauseated with no vomiting, rebound tenderness in right lower quadrant, has elevated WBC's and surgeon feels this will be uneventful even though he has just been diagnosed with AIDS this past week. His overall health is good, and he has known he has been HIV positive for the past five years. He has been taking his HIV medication daily. Recently he manifested an unusual black lesion on his thigh and developed an opportunistic fungal mouth infection which was treated successfully. The lesion was identified as Kaposi's Sarcoma. Now, meeting the CDC definition, he has full blown AIDS but is asymptomatic at this time. Mr. Dominec has a male partner and has been married for the past ten years and share their three children to the marriage. Your Description Response Explanation Acute Pain True Status Assessment reports rebound tenderness related to Ap Bleeding False Patient would be at Risk for Bleeding for upcoming surgery Chronic Pain False Status assessment reports no indication of Chronic Pain Constipation False Status assessment reports no indication of constipation Knowledge False Status Assessment reports upcoming surgery and recent diag Deficit Nutrition False Status Assessment reports has had nausea for several days a Risk for Infection True Status Assessment reports upcoming surgical incision and co immunocompromised from AIDS diagnosis Skin integrity at True Status Assessment reports wound healing from upcoming inc Description risk Your Response Explanation Love and Belonging Description Your Response Explanation Compromised Family Coping False Status assessment reports no indication of C Coping Fear/Anxiety False Status Assessment reports facing new surger 1Perform full assessment and provide 3 anti-nausea medicine. 2Provide comfort in pre-surgical room 4 Mr. Dominec. 3Check surgical consent for correct 2 procedure and make sure operative site in marked. 4Inform his partner that everything is 1 being done to keep him comfortable. 1Educate about recovery from 1 appendectomy and care to wound. 2Discuss his understanding about the 5 plan of care. Medicate as ordered to treat nausea. Nurse should recognize for the patient to remain in a stretcher may not be as comfortable as a bed. Checking surgical consent is essential before pre-op medication is administered. Encourage partner to remain with patient pre-operatively to lessen anxiety of impending surgery. Education post op assures the best outcomes with patient participation and understanding. Evaluation of his understanding about his plan of care determines his level of understanding. 3Discuss follow up with his doctor. Follow up with his doctor allow for 2 adjustments in care if needed. 4Offer assistance in providing more 4 information about treatment options for newly diagnosed AIDS patients. 5Determine from medical record if 3 partner is aware of his recent AIDS diagnosis. 1You discuss this cough with Mr. 1 Dominec to determine how long he has had it. 2Notify doctor of change in condition Since newly diagnosed with Kaposi's sarcoma, assess his knowledge of treatment options. Partner awareness of diagnosis can facilitate emotional support in this newly diagnosed disease. Assessing how long the dry cough has occurred is important to determine dosage for medicine. Time is very important in treating a PCP 4 in particular: unproductive cough and (pneumocystis carinii) lung infection. low-grade fever. Medication (Bactrim) should be started immediately. 3Explain to Mr. Dominec your concern 2 for this opportunistic infection and usual treatment. 4Explain that he will probably not be 3 going home at least until his doctor sees him. 5Notify charge nurse that discharge 5 will probably not occur today. Education assures the best outcomes with patient participation and understanding. Evaluation is key to making sure of proper understanding of education. 1 1Inform patient about the progression and risk a PCP infection has for a patient with AIDS. 2Obtain and provide the infectious 3 disease doctor's contact information for him. 3Encourage Mr. Dominec to discuss 2 with his partner his best treatment options. 4Take vital signs before leaving the 4 hospital again. 5Document and provide copy for Mr. 5 Dominec to share with his follow up appointment tomorrow. Informing patient of risks in not getting treatment for his dry cough may change his mind. Provide information about PCP infections and other opportunistic infections and treatment. Involve his partner in this decision not to receive treatment may change patient's mind. Repeat vital signs before patient leaves hospital to determine if condition has deteriorated and is best practice for patient. Respect and support his decision to deny tr 1This information is HIPAA protected and you 3 cannot share anything with them. 2Remind staff that Universal Precautions are 1 practiced at this hospital for all patients regardless of known infectious diseases. 3Leave the break room and not continue in 2 conversation. 4Report this activity immediately to the 5 hospital privacy officer 5Report to charge nurse/ head nurse the need 4 for staff education. Inform staff of the HIPAA laws in place and how this discussion can violate those laws. Remind staff that every patient regardless of disease follows same universal precautions. Leave break room to end discussion and further violations of HIPAA mandates. Reporting to hospital privacy officer is required by policy. Notifying superior when an issue occurs in case some intervention is needed immediately. Ann Rails, 38 years old, c/o back pain, non-significant past medical history. No known allergies (NKA). Vital signs -BP 124/82, Temp 98.2, P 84, RR 22, SaO2 96%. Pain and numbness in legs for one week. Abnormal left leg weakness, gait unsteady, 5/10 on numeric pain scale. Neuro WNL, except leg pain upon movement. Activity as tolerated with assistance. D/C plan- decrease pain and restore normal gait. Regular diet. Dr. Suculo Acute Pain True Status assessment reports patient experiencing pain & numbn Bleeding, Risk for False Status assessment reports no indication of incisions or wounds Chronic Pain False Status assessment reports non-significant past medical hx Impaired Comfort True Status assessment reports patient experiencing pain upon mov Impaired Mobility True Status assessment reports patient experiencing gait weakness, Nausea False Status assessment reports no indication of 'Nausea' Safety Description Your Response Explanation Deficient Knowledge False Status assessment reports no indication of Disturbed Sensory Perception False Status assessment reports patient experien Fall, Risk for True Status assessment reports patient experien and numbness Grieving False Status assessment reports no indication of ' Infection, Risk for False Status assessment reports no indication inc Peripheral Neurovascular False Status assessment reports patient experien Dysfunction Kathy Gestalt, 33yr-old, Dx- second day post-op open right Tibia/Fibula fracture, plaster cast in place on right lower leg. No known allergies. Vital signs -Temp 98.4, BP 116/76, P 96, RR 20, SaO2 99%. Neuro WNL, alert, and cooperative but worried about scarring and is reluctance regarding walking on leg. Diet as tolerated, up ad lib after gait training. Crutches at bedside adjusted for height. Dr. Anderson Category Your response Explanation Educational Needs Increased acuity Status assessment reports patient second day post-op. Worried about scarr Fall Risk Increased Status assessment reports patient second day post-op, cast in place on rt le acuity Health Change Increased acuity Pain Level Increased acuity crutches. Status assessment reports patient second day post-op open rt tib/fib fractu Patient is a second day post-op open right Tibia/Fibula fracture Psychological Needs Normal acuity Status assessment reports patient worried about scarring, reluctant regardi Sensorium Normal acuity Status assessment reports no indication of increased sensorium acuity Acute Pain related to surgery as evidence by patient Tru Status assessment rep verbalizing pain. e medical diagnosis, tib/ Chronic Pain Fals Status assessment doe Impaired Mobility related to broken bone as evidence by plaster cast and pateints relucatance to walk. e Tru e pain. Status assessment rep diagnosis. Impaired Skin Integrity, Risk for Tru e Status assessment rep Ineffective Peripheral Tissue Perfusion Fals Patient could be "at ris e Peripheral Tissue Perfu Self-Care Deficit Tru e Patient could be "at ris Safety Your Description Response Expla Anxiety False Status assessment repo and worries. Deficient Knowledge True Status assessment repo crutch training. Fall, Risk for True Status assessment repo crutches. Grieving False Status assessment repo 'Grieving'. Impaired Home Maintenance Management r/t Client True Patient discharge nursin or Family addressed. Peripheral Neurovascular Dysfunction False Status assessment indic concern. Esteem Description Your Response Explanation Decisional Conflict False Status assessment reports patient relu Deficient Diversional Activity False Status assessment reports no indicatio Disturbed Body True Status assessment reports patient worr Hopelessness False Status assessment reports no indicatio 11 Check pedal capillary refill Assessment is the first step of nursing process. 22 Educate patient Education is to be achieved after understanding patient a 33 Evaluate understanding Evaluation should be performed after patient education. 44 Adjust crutches Should be completed before assisting patient and after ed 55 Assist patient out of bed Your order Correct order Step Explanation 1 1 Wash and glove hands First step in patient assessment/intervent 2 2 Vital assessment Assessment is the first step of nursing pr 3 3 Administer antipyretic meds To be completed after assessing tempera 4 4 Verify call light/bed safety precautions After patient care, always place call light lowest position. 5 5 Document results/findings Accurate documentation is to be perform performed, NEVER BEFORE! 1Inspect cast site Assessment: cast should allow for movement unless 2 2Assess toe movement and 1 capillary refilling Palpate for refilling less than two second refilling. 3Notify doctor if condition is Abnormal condition of blood circulation in foot should 3 abnormal to prevent tissue damage. 4Document Results/Findings Accurate documentation is to be performed after pat 4 NEVER BEFORE! 1 1 Elevate Extremity Elevation of foot is most important to prevent 2 2 Assess pain Assessment is the first step of nursing process 3 3 Educate patient regarding condition Education is to be achieved after understandin 4 4 Notify lead nurse/doctor Emergencies require doctor notification. 5 5 Retrieve cast removal tool Gather tools after order from doctor. Use therapeutic 1 communication/Active Listening Therapeutic Communication assessment is first step to understanding patient condition. 2 Notify lead nurse/doctor Doctor must writ 4 social service. 3 Consult Social Service Social service sh 2 consult plan. 4 Evaluation patient after consult Evaluation of pla 3 5 Document Results Accurate docume 5 performed after NEVER BEFORE! Virginia Smith, 57-year-old who has elected to have a total mastectomy based on consultation with her surgeon, a total mastectomy removes all breast tissue but leaves all or most of axillary lymph nodes and chest muscles intact. She is also to receive radiation, chemotherapy, and hormone therapy post operatively. She is with her physician. She is also investigating bone marrow transplantation. She has arrived in pre-op and about to have surgery this morning. Her husband and two grown children are also with her as she is prepared with gown and head cap awaiting transport to the operating room. She has IV access and has received a small dose of Valium to reduce apprehension. Temperature is 98.3, HR is 87, RR is16, BP is 121/74, PaO2 is 98%. Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. Palliative care. No Known allergies (NKA). Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Neuro WNL alert and cooperative. Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. Blood Glucose 185, 4 units of insulin sliding scale for coverage. ADA diet, intake 25%. Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. Patient and family upset regarding dx. Dr. Donofrio Bleeding, Risk for True Status assessment reports no indication of incisio Chronic Pain True Status assessment r/t medical dx. Constipation, Risk for True Status assessment reports patient's side effects fr management. Decreased Cardio Tissue Perfusion Fals e Status assessment reports no indication of cardio Imbalanced Nutrition True Status assessment reports patient's diet intake is Impaired Skin Integrity Fals Status assessment reports no indication of skin in e Safety Your Description Response Expla Anxiety False Status assessment repo upset. Deficient Knowledge True Status assessment repo nursing concern. Fear False Status assessment repo upset. Grieving False Status assessment repo upset. Impaired Home Maintenance management r/t client or family True Status assessment repo nursing concern. Ineffective Self-Health Management True Status assessment repo nursing concern. Esteem Description Your Response Explanation Disturbed body False Status assessment reports no indication of nursin Hopelessness False Status assessment reports patient and family ups Noncompliance True Status assessment reports no indication of nursin Powerlessness False Status assessment reports patient and family ups 1Wash and glove hands Mandatory with all patients especially with immunoc 1 2Full assessment Follow up clarification with assessment of patient's p 2 3Seek clarification Assessment with correct therapeutic communication 4 4Check PRN pain order Patient's affect doesn't match statement, be prepare 3 medications. 5Verify call light/bed safety After patient care, always place the call light within r 5 precautions position. 1 1 Full assessment Assessment establishes baseline condition/ 2 Educate patient regarding changes to 2 POC Priority with new mode of pain control. 3 Place patient on PCA pump Can be accomplished only after education/a 3 4 Observe closely first hour After patient is on pump, nurse must monit 5 5 Perform pain re-assessment After proper functioning is achieved, effecti 4 1Use therapeutic communication/active 1 listening Therapeutic Communication is first step to un condition. 2Educate patient/family After understanding wishes, educate patient a 2 advocate. 3Notify doctor Doctor will write order for Social Services 4 4Contact Social Services Provide Social Services with doctors' orders an 3 5Report and document results Accurate documentation is to be performed af 5 NEVER BEFORE! 1 1 Use therapeutic communication/Active Listening Proper Therapeutic Communication 22 Notify doctor for Foley catheter Doctor will write orders for Foley ca 33 Education of Foley Cath Procedure After receiving order, education for 44 Insert Foley catheter After education, insert catheter usi 55 Document Procedure Record catheter type, size, toleranc 1Allow family to remain Top priority answers immediate concern. 1 2Full assessment Assessment is the first step in the nursing process. 2 3Provide comfort and pain Planning/Intervention is the second/third step in the nur 3 measures 4Pain re-assessment Assessment, Planning, Intervention, Evaluation. 4 5Document results Accurate documentation is to be performed after patien 5 NEVER BEFORE! 1Therapeutic communication Therapeutic communication sets up the caregiv 1 dialogue with the patient. 2Validate NPO Status NPO assures less complications with anesthesia 2 3Encourage to ambulate with Emptying the bladder before surgery reduces po 3 assistance to void if needed. post-operative. Should be done prior to connect 4Connect telemetry Telemetry establishes safety for the patient duri 4 with continuous cardiac monitoring. 5Provide a few chairs if possible for her Providing chairs for family members waiting wit 5 family to also be comfortable lessen anxiety with patient. However, patient ca 1Vital signs taken by automatic B/P cuff q Vital signs are monitored at least every 15 m 3 15 minutes. 2Complete assessment. Assessing the patient allows the nurse to es 2 reference. 3Talk with her stating surgery is over and Communication assures neurological alertne 1 she did great. 4Allow husband to make a quick one- 4 minute visit. reduces post-op anxiety. The husband’s visit provides comfort for bot member. 5Document and prepare to transfer to The Surgical ICU must have accurate docum 5 Surgical ICU. status in progres Provide Operative 1 summary of type of Establishing "big picture" so ICU unit knows what type of patient is coming procedure, IV fluid and pain and what likely to expect. Think SBAR. status. 2 Present health assessment including B/P 1 and LOC and dressing. Starting with LOC assessment and b 3 Report current urinary output quantify Fluids and output 4 per hour and color of urine internal bleeding. 4 Request time she can arrive and staff to 3 help with transfer 5 Explain to her family and provide 5 contact information. Requesting time g get ready for arriv quality of care. Letting the family they can be ready needed. Family co care. 1Full assessment of patient. Assessment is essential upon receiving the patie 2 2Provide for physical and thermal 3 comfort. and patient plan of care. Patients returning from surgery are often therm warmth and comfort once in bed. 3Therapeutic communication. Talking to patient provides essential information 1 4Begin post op education for day one. Establishing post op education immediately give 4 involvement in their care. 5Notify family as to when they may Letting family know keeps them in the loop of in 5 come and visit. good support. Marcella Como, 38 yr-old, Sexual Trauma Victim (Rape), unknown assailant. Non-significant past medical Hx. No known allergies (NKA). Vital signs -Temp 98.2, BP 94/60, P72, RR 22, SaO2 99%. Multiple abrasions, bruising Head, chest, and inner thigh. Isolative, appears fearful, crying, and refusing to see her husband. SANE nurse to make second visit today. Awaiting diagnostic labs. Taking HIV Meds prophylaxis. Social worker with patient this morning. Diet as tolerated. Dr. Roopes Description Your Response Explanatio Acute Pain False Status assessment reports patient w medical dx. Impaired Mobility False Status assessment reports no indicat movement. Impaired Urinary Elimination False Status assessment reports no indicat Readiness for Enhanced Immunization Status Safety False Status assessment reports patient's prophylaxis meds. Description Your Response Explanation Chronic Confusion False Status assessment reports no indication of chro Fall, Risk for False Status assessment reports no indication of risk Description Your Response Explanation Fear True Status assessment reports patient's current dis Grieving False Status assessment reports patient's current dis Infection, Risk for True Status assessment reports medical dx. Sleep Deprivation Love and belonging False Patient possibly "at Risk" for nursing dx. Description Your Response Explanation Anxiety True Status assessment reports patient's cur Body Image, Disturbed False Status assessment reports no indication Chronic Sorrow False Patient possibly "at Risk" for nursing co Compromised Family Coping False Status assessment reports patient's res Powerlessness True Patient possibly "at Risk" for nursing co Social Isolation True Status assessment reports patient's cur Esteem Description Your Response Explanation Decisional Conflict False Status assessment reports no indication of dec Ineffective Coping True Status assessment reports patient not allowing Noncompliance False Status assessment reports no indication of non Rape-Trauma Syndrome True Status assessment reports patient's medical d Self-actualization Description Your Response Explanation Disturbed Energy Field False Status assessment reports patient's isolativ Spiritual Distress False Status assessment reports no indication of Your Correc orde r t order Step Explanation 1 1 Use therapeutic communication/Active Listening Using therapeutic communication to assess is first step to understanding patient's psychological condition. 2 2 Full Assessment Full assessment is first step of establishes baseline of patient's physiological condition. 3 3 Provide emotional support After proper assessment, provide proper planning and intervention. 4 4 Documentation Document patient baseline assessment information for progression of patient. 1 1 Use therapeutic communication/Active Therapeutic Communication Assessment is first step to understanding patient Your Correc orde t r order Step Explanation Listening request/concerns. 2 2 Educate patient Feeling of being "dirty" is common for rape victims. 3 3 Provide supplies and Demonstrates care for the patient. Patient may needed instructions. have questions regarding supplies or new surroundings. 4 4 Offer to Assist After receiving supplies and instructions patient may see obstacles where help may be needed. Also, interaction could diminish feelings of abandonment, isolation, and untouchability. Your order Correct order Step Explanation 1 1 Use therapeutic Listening to verbal & nonverbal communication/Active Listening messages for patient intent. 2 2 Ask open-ended questions Allows more opportunity for discussion. 3 3 Seek clarification Narrows down open-ended questions. 4 4 Summarize discussion States main points & allows for further planning. Your order Correct order Step Explanation 2 1 Restate or Conveys listening & understanding of paraphrase patient message. statements 1 2 Acknowledge Gives acceptance to wishes of patient after patient's decision restating/paraphrasing. 3 3 Review plan of action Marks beginning of next phase of POC. 4 4 Notify social services Notifying social services is next step of plan of action. 5 5 Document process Accurate documentation is to be performed after patient care is performed, NEVER BEFORE! Your order Correct order Step Explanation 1 1 Review Labs Negative/positive test results will dictate Your order Correct order Step Explanation Education. 3 2 Educate Patient-STD's and pregnancy Education is achievable after understanding patient concerns. 2 3 Provide emotional support Nurse is to act as patient advocate and support person. 4 4 Discuss Support Groups Secondary issue designed to help victims with self-care. Ramona Stukes, 69 yr-old, third day post-op cholecystectomy. Non-significant past medical history. No known allergies (NKA). Vital signs -Temp 98.6, BP 114/62, P 100, RR 20, SaO2 94%. Neuro WNL, alert, and cooperative. Skin warm and dry, daily dressing changes, T-tube without drainage. NG tube to low suction possibly D/C'd today after Dr. Levine rounds. Today's incentive spirometry Tidal Volume is 1250ml, improvement over yesterday's 900ml. NPO with small amount of ice chips only. Today's weight 226. IV D5 1/2 NS with 20 KCL @ 125 ml/hr in left forearm. Last pain medicine 2hrs ago at 1300(Demerol 50mg/ Zofran 4mg IV). Ambulates with assistance. Dr. Levine Bleeding, Risk for Fals Status assessment reports surgical site e Constipation Fals Patient would be "at Risk" for nursing concern. e Deficient Fluid Volume, Risk for Tru Status assessment reports patient is receiving trea e nursing concern. Dysfunctional Gastrointestinal Motility Fals Patient would be "at Risk" for nursing concern. e Imbalanced Fluid Volume Fals Patient would be "at Risk" for nursing concern. e Impaired Mobility Tru e Status assessment reports patient's surgical site a Safety Description Your Response Explanation Anxiety False Patient would be "at Risk" for nursing co Fall, Risk for True Status assessment reports patients need ambulation. Ineffective Self-Health Management False Status assessment reports no indication Infection, Risk for True Status assessment reports surgical site. Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma. Hx of dementia, from nursing home, fall one day ago. No known allergies (NKA). Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. Neuro- confusion to time and place, but oriented to self, speech clear, poor historian, did not recognize son today which is new for her; Neuro assessment and vital signs q1 hr. Skin warm dry, bruises on forehead with small laceration. Increased fall risk. DSD (dry sterile dressing), forehead laceration clean and dry intact. 20ga. Hep-Lock in place left AC. GI WNL. Cardiovascular has pacer with rate of 82bpm on demand. Strict I&O, regular diet, intake 50%. Waist belt restraint PRN; family sitter at bedside, assist with bath. Dr. Altace Description Your Response Explanation Bleeding, Risk for True Status assessment reports patient experienced hea Decreased Cardiac/perfusion False Status assessment reports no indication cardio issu Imbalanced Nutrition True Status assessment reports patient with 50% diet co Nausea False Status assessment reports no indication of 'Nausea' Self-Care Deficit True Status assessment reports patient experiencing con assistance with ADL's. Shock, Risk for False Status assessment reports no indication of symptom Safety Description Your Response Explanation Acute Confusion True Status assessment reports patient disorient Fall, risk for True Status assessment reports patient history o Peripheral Neurovascular Dysfunction False Status assessment reports no indication of ' Dysfunction'. Sleep deprivation False Status assessment reports no indication of i Love and belonging Description Compromised Family Coping Your Response Explanation False Status assessment reports no indication of curre Failure to Thrive True Status assessment reports patient exhibits decre inabilities Tom mrdson, 46yr-old. Dx- urinary stones with 3 episodes/5yrs. Allergic to sulfa drugs. Vital signs -Temp 98.4,BP 178/105, P 112, RR 28, SaO2 94%; Neuro- WNL's. Skin warm and pale. Generalized weakness, blood tinged urine and severe pain upon urination, GI- n/v. Clear liquid diet. Strict I&O and strain all urine, filters in bathroom. Patient demonstrates urine strain procedure. Severe pain (10/10) medicated q 30 minutes x4 with IV Morphine 2mg with little relief. IV D5 1/2 NS @150ml/hr. Dr. Small at bedside with patient and family. Stat lithotripsy treatment ordered. Awaiting transport. Acute Pain Tru e Status assessment report of pain. Electrolyte Imbalance Fals Patient would be "at Risk" for nursing concern. e Imbalanced Nutrition Tru e Status assessment reports no indication of nursing conc Impaired Mobility, Risk for Fals Status assessment report of pain, weakness, and pain m e mobility difficulties. Impaired Skin Integrity, Risk Tru Status assessment reports no indication nursing concern for Impaired Urinary Elimination Safety e Tru e Status assessment report r/t medical diagnosis Description Your Response Explanation Fall, Risk for True Status assessment reports weakness, severe pain, and freque patient at risk for fall Sleep Deprivation False Patient would be "at Risk" for nursing concern; however, pain for rest. Sarah Getts, 77 yr-old, Dx- Chronic Renal Failure, admitted with hyperkalemia (5.9, Eq/L)/hyponatremia (128mEq/L). No known allergies (NKA). Vital signs -Temp 98.8, BP 102/76, P 102- irregular, RR 22, SaO2 90%, cardiovascular on telemetry with Sinus irregular rhythm. Disoriented to time and place, speech slurred. Pupils PERRLA, eyes clear. 20 ga. Hep-Lock in right forearm, skin warm and dry, generalized weakness with recent weight loss. 50% intake. High fall risk. Renal diet. Family in room with patient very concerned. Dr. Brown Physiological Your Description Response Explanatio Acute Pain False Status assessment reports no indica Deficient Fluid Volume True Patient would be "at Risk" for nursin Electrolyte Imbalance True Status assessment report regarding Imbalanced Fluid Volume, Risk for True Status assessment report r/t medica Your Description Response Explanatio Impaired Skin Integrity, Risk for False Status assessment reports no indica Ineffective Renal Perfusion, Risk for True Status assessment report r/t medica Safety Your Description Response Explanation Acute Confusion True Status assessment reports patient is dis Disturbed Sensory Perception False Status assessment reports patient's diffi Fall, Risk for True Status assessment reports patient is dis Sleep Deprivation Love and belonging False Patient would likely be more likely to sle Description Your Response Explanation Anxiety False Patient possibly at Risk for nursing concern. Failure to Thrive True Status assessment reports as medical diagnosis a 1Wash and glove 1 hands First step in patient assessment/intervention. 2Full assessment Change in condition warrants full assessment. 2 3Apply fall risk 3 bracelet Notifies staff of patient fall risk enhancing patient safety. 4Document results Accurate documentation is to be performed after patient care is 4 BEFORE! 1 1Offer assistance Patient advocate is priority. 2Remain with patient Provide safety and comfort to patient. 2 3Therapeutic 3 Communication Demonstrates caring to patient. 4Notify lead nurse Team Lead should be notified. 4 5Document results Accurate documentation is to be performed after patient ca 5 BEFORE! 2 1 Visual assess Assessment is the first step of nursing process. 3 2 Call rapid response Patient assistance is number one priority. 1 3 Apply oxygen ABC's priority. 5 4 Establish second IV Proactive for possible heart cath lab visit. 4 5 Remain with patient Provides security for patient. 1Give verbal report To give proper report remember SBAR: Situation, Background, Asse 1 Recommendation. 2Escort patient Most HCP require RN to escort patients to UCI units. 2 3Notify family Patient is priority; now update family to patient's location and statu 3 4Document results Accurate documentation is to be performed after patient care is per 4 CARLOS 48yr-old, Spanish speaking migrant worker with no known past medical Hx. Rule out Tuberculosis. Vital signs -Temp 99.1, BP 124/62, P 77, RR 20, SaO2 91%. Airborne Isolation. Neuro WNL. Skin moist, respiratory bilateral wheezes and rhonchi. Blood-tinged mucous, productive cough. Diet as tolerated. IV maintenance fluids with D5 1/4 NS @ 150 ml/hr X 3 then reduce rate to 75 ml/hr. Expresses fatigue, fear, concern, and desire for recovery. Need frequent reminder to stay in room and maintain mask precautions. If family/visitors come, will need education to airborne precautions. Spanish interpreter available at extension 61178. Dr. Rondeau Physiological Description Your Response Dysfunctional Gastrointestinal Motility False Status asse concern. Electrolyte Imbalance False Status asse imbalance. Fatigue True Status asse Impaired Gas Exchange related to infection as evidence by wheezing True Status asse secretion. Impaired Mobility False Status asse Ineffective Airway Clearance related to --- as evidence by cough True Status asse secretion. Safety Description Your Response Anxiety True Status assessment repo Deficient Knowledge False Status assessment repo Fall, Risk for True Status assessment repo Fear True Status assessment repo Hypothermia False Status assessment exh Impaired Home Maintenance Management False Status assessment repo Love and belonging Your Description Response Expla Chronic Sorrow False Patient may be experiencing ACUTE sorrow r/t Social Isolation, Risk for Esteem True Status assessment of 'if family/visitors come' Description Your Response Ex Decisional Conflict False Status assessment reports no indication Noncompliance Self-actualization True Status assessment reports patient needs Description Your Response Readiness for Self-Care Enhancement True Status assessment repor Spiritual Distress False Status assessment repor 1Don Personal Protective 1 Equipment Follow airborne safety precautions prior to entering the room. 2Allow for non-compliance Patient has right to non-comply. 3 of request 2 3Do not probe further Respect patient's decision. 4 4Verify call Light/bed safety precautions After patient care, always place call light in reach and bed in lowest position. 5 5Document results Accurate documentation is to be performed after patient care is performed, NEVER BEFORE! 1 1Obtain translator Translator is required for effective communication. 5 2Offer masks to visitors Mask prevents communicable diseases 2 3Educate patient Education should come after patient and staff safety. 3 4Evaluate understanding Performed after education. 4 5Obtain Spanish signs & brochure Signs will help new visitors understand disease transmission. Your order Correct order Step Explanation 4 1 Obtain translator Translator before entering the room is required Your order Correct order Step Explanation for effective communication. 2 2 Wash Hands First step in patient assessment/intervention. 1 3 Put on gown and mask Don personal protective equipment (PPE) gown and mask. 3 4 Don Gloves Don gloves after gown and mask 5 5 Administer antipyretic medication 101.2 temperature should be addressed prior to educating patient regarding fluid 1Educate caller regarding 1 HIPAA 2Evaluate caller 2 understanding 3Refer caller to contact 3 health department Information cannot be given out over phone without prearranged consent. Evaluate Understanding - follows patient education. Appropriate step can be accomplished once understanding is recognized. 4Notify doctor Doctor should be notified of patient home condition for 4 necessary treatment adjustments. 5Document conversation If it's not documented, IT DIDN'T HAPPEN! 5 1 1Obtain translator Translator is required for effective communication. [Show More]

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