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swift river med surg pt scenarios
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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 - ANSWER Educational Needs Increased acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Increased acuity Psychological Needs Normal acuity Sensorium Normal acuity Ramona Stukes - ANSWER Physiological Bleeding, Risk for True Constipation False Deficient Fluid Volume, Risk for True Dysfunctional Gastrointestinal Motility False Imbalanced Fluid Volume False Impaired Mobility True Safety Anxiety False Fall, Risk for True Ineffective Self-Health Management False Infection, Risk for True Ramona Stukes Scenario 1 Mrs. Stukes is a failed laparoscopic cholecystectomy that resulted in a bowel resection with a temporary ileostomy in place. Now, third day post-op, Mrs. Stukes appears sad and depressed upon entering the room. Scenario 2 Mrs. Stukes is feeling nauseated.
Scenario 3 Mrs. Stukes's appliance is leaking for the fourth time today and has been changed and reapplied each time. She is frustrated and overwhelmed with the new appliance not working properly. Scenario 4 Mrs. Stukes's husband is not willing to help assist patient upon discharge with her stoma care for failed laparoscopic cholecystectomy. Scenario 5 Three days after discharge, you receive a phone call from Mrs. Stukes's neighbor, who is helping take care of her. She is requesting the names and home phone number for the wound care nurse who saw Mrs. Stukes while she was an inpatient. - ANSWER Scenario 1 Wash and glove Hands Full assessment Allow expression of feelings Educate patient Evaluate understanding Scenario 2 Wash and glove up Full assessment Check Ng tube placement Administer IV antiemetic medication Scenario 3 Full assessment Educate patient Evaluate understanding Notify lead nurse and doctor Consult Wound Care Scenario 4 Discuss with patient identify home health needs Notify lead nurse/doctor of new circumstances Contact Social Services for new consult Update patient on discharge changes Scenario 5 Follow HIPPA Protocol Explain HIPPA Protocol Offer resource assistance to caller Contact Wound Care directly Document Conversation
Disturbed Energy Field True Spiritual Distress False Marcella Como Scenario 1 Ms. Como is first day after sexual assault. Upon entering the room, she is quiet and shows little emotion. Scenario 2 Later in morning care, Ms. Como requests to take a shower stating she feels 'dirty'. Scenario 3 In the afternoon, Ms. Como is stating that she does not want to see her husband or any visitors. (Think Therapeutic Communication) Scenario 4 Marcella Como is now more talkative and shares with you that she is going to cooperate and wants to press charges against the assailant. Scenario 5 Marcella is very worried about STD's and possible pregnancy. - ANSWER Scenario 1 Use therapeutic communication/Active Listening Full Assessment Provide emotional support Documentation Scenario 2 Use therapeutic communication/Active Listening Educate patient Provide supplies and needed instructions. Offer to Assist Scenario 3 Use therapeutic communication/Active Listening Ask open-ended questions Seek clarification Summarize discussion Scenario 4 Restate or paraphrase patient statements Acknowledge patient's decision Review plan of action Notify social services Document process
Scenario 5 Review Labs Educate Patient-STD's and pregnancy Provide emotional support Discuss Support Groups Estelle Hatcher, 31yr-old, r/o appendicitis, 1st day post-op appendectomy; No known allergies (NKA); Vital signs - Temp 101.2, BP 108/74, P 92, RR 20, SaO2 99%, alert and cooperative. Wound site clean, dry and intact NPO, NG-tube to low continuous suction. IV maintenance fluids with D5 1/2 NS with 20 KCL @ 125ml/hr in left forearm. Ambulates with minimal assistance. Family at beside. Dr. Sangerstien - ANSWER Educational Needs Increased acuity Fall Risk Increased Acuity Health Change Increased Acuity Pain Level Increased Acuity Psychological Needs Normal Acuity Sensorium Normal Acuity Estelle Hatcher - ANSWER Physiological Activity Intolerance False Acute Pain True Diarrhea False Electrolyte Imbalance, Risk for True Impaired Comfort True Impaired Mobility False Safety Deficient Knowledge True Fall, Risk for True Fear False Ineffective Self-Health Management False Infection, Risk for True Sleep Deprivation False Estelle Hatcher Senario 1 Ms. Hatcher is second day post-op and has a nasogastric tube set to gravity drainage only. She presses call light with questions about who her nurse will be and her NG-tube. Senario 2 During the follow up nursing assessment, Ms. Hatcher complains about the nasogastric tube causing her pain in her nasal area. She has active bowel sounds.
Carlos Mancia, 48yr-old, Spanish speaking migrant worker with no known past medical Hx. r/o 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 - ANSWER Educational Needs Increased acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Normal acuity Psychological Needs Increased acuity Sensorium Normal acuity Carlos Mancia - ANSWER Physiological Dysfunctional Gastrointestinal Motility False Electrolyte Imbalance False Fatigue True Impaired Gas Exchange True Impaired Mobility False Ineffective Airway Clearance True Safety Anxiety True Deficient Knowledge True Fall, Risk for False Fear True Hypothermia False Impaired Home Maintenance Management False Love and belonging Chronic Sorrow False Social Isolation, Risk for True Esteem Decisional Conflict False Noncompliance True Self-Actualization
Readiness for Self-Care Enhancement True Spiritual Distress False Carlos Mancia Scenario 1 Mr. Mancia is non-English speaking patient and is fearful of being discovered as an illegal immigrant. Upon entering the room with a translator to admit him to the hospital, he is asked for address and phone number but refuses to comply. Scenario 2 Upon entering room, you wash/glove hands. Following isolation precautions, you notice several family members are by his bedside and none of them are wearing face masks as requested by sign on door. Scenario 3 Mr. Mancia's vital signs upon assessment are Temp 101.2, P 94, RR 20, BP 122/82, SaO2-91%. Scenario 4 The sister of Mr. Mancia calls from home to speak with you. She shares concern about patient's wife who is now coughing and having night sweats. Scenario 5 Mr. Mancia is holding Catholic Rosary in hand and is crying as you enter the room. - ANSWER Scenario 1 Don Personal Protective Equipment Allow for non-compliance of request Do not probe further Verify call Light/bed safety precautions Document results Scenario 2 Obtain translator Offer masks to visitors Educate patient Evaluate understanding Obtain Spanish signs & brochure Scenario 3 Obtain translatorT Wash and glove hands Gown and mask Administer antipyretic medication Encourage fluids
Day 2 admission, Thomas Richardson is complaining of severe pain and is now begging you for some relief; states pain scale 10/10. Senario 2 Mr. Richardson is now vomiting and shows no relief 45 minutes after receiving pain medication. Senario 3 Mr. Richardson is requesting assistance to ambulate to bathroom. Senario 4 Mr. Richardson is now pain free and questioning why he is plagued with recurring urinary stones. Senario 5 You are now preparing for discharge, place steps in order: - ANSWER Senario 1 Wash and glove hands Vital assessment Administer pain medications Re-assess patient Document results Senario 2 Vital Assessment Notify Doctor for pain medz Administer new pain medz Re-assess patient Senario 3 Use therapeutic communication/Active Listening Obtain urinary screen Assist patient Remain with patient Document results and findings Senario 4 Use therapeutic communication/Active Listening Educate patient Evaluate understanding Contact dietary consult Document results Senario 5 Discharge instructions Evaluate understanding Escort patient to vehicle
Document results Notify housekeeping John Duncan, 56yr-old male, Dx- Gastroenteritis, returned yesterday from Cancun, c/o intractable diarrhea, weak, pale, and refusing to eat. No known allergies (NKA). Non- significant past medical Hx. Vital signs Temp 99.4, BP 106/72, P 96, RR 20, SaO2 91%. Neuro WNL's, alert and cooperative. IV maintenance fluids with D5 1/2 NS at 125ml per hour in left forearm. c/o headache- medicated with Lortab 5mg PO at 0900, takes Lomotil 10ml PRN q 4 hours last dose at 0834. Stools are decreasing but patient remains very weak. Wife at bedside. Diet as tolerated. Dr. Jones. - ANSWER Educational Needs Increased acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Increased acuity Psychological Needs Normal acuity Sensorium Normal acuity John Duncan - ANSWER Physiological Deficient Fluid Volume True Electrolyte Imbalance, Risk for True Excess Fluid Volume, Risk for False Fatigue True Nausea False Self-Care Deficit False Safety Fall, Risk for True Infection, Risk for False Esteem Ineffective Coping False Noncompliance True John Duncan Scenario 1 As you enter the room, Mr. Duncan is refusing to eat foods from bland diet. Senario 4 Mrs. Hatcher appears restless, diaphoretic and calls nurse for help. Upon entering room, what order of appropriate steps do you take? Senario 5 Several hours later, Mrs. Hatcher is feeling much better. She puts on her call light and asks to see a nurse. Upon entering the room, she asks you if she will be able to drive when she gets home tomorrow. - ANSWER Senario 1
Sensorium Normal acuity Viola Cumble - ANSWER Physiological Acute Pain True Bleeding, Risk for True Constipation False Impaired Mobility True Impaired Skin Integrity, False Ineffective Peripheral Tissue Perfusion False Safety Acute Confusion False Deficient Knowledge False Fall, Risk for True Ineffective Self-Health Management True Infection, Risk for True Peripheral Neurovascular Dysfunction False Viola Cumble Senario 1 Ms. Cumble states that she has not had a BM for three days. Senario 2 Ms. Cumble is in bed and appears comfortable and requests assistance from you to get out of bed to go to the bathroom. Senario 3 Vital signs are to be taken BID, and it is now time. Scenario 2 Mr. Duncan is now complaining of feeling "dizzy" when he stands. Scenario 3 Several hours later, Mr. Duncan is now complaining of nausea. Scenario 4 Two hours later, Mr. Duncan is asked how frequent his stools have been today. He replies, "six times in the past four hours". He also states he is feeling weak. Scenario 5 Mr. Duncan's wife meets you in hall asking what she could bring her husband to eat from home. - ANSWER Scenario 1 Assess intake and output and possible reasoning
Construct dietary consult (plan) Acquire daily weight and food intake Evaluate outcome of dietary plan Scenario 2 Full assessment including both lying/standing Check input/output for possible dehydration Teach patient about safety when getting out of bed Document findings Scenario 3 Wash and glove hands Provide emesis basin/cloth Vital assessment Administer antiemetic medication Evaluate medication effectiveness Scenario 4 Vital assessment Assessment of bowel movement Administer protocol antidiarrheal medication Document results/findings Include patient condition change in shift report Scenario 5 Inform and educate spouse of dietary orders Evaluate/modify plan of care Assess food consumption and intake and output Document findings/results 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 - ANSWER Educational Needs Increased acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Increased acuity Psychological Needs Normal acuity Sensorium Normal acuity Ann Rails - ANSWER Physiological Acute Pain True Bleeding, Risk for False
Scenario 3 Listen to patient concerns Reassure patient of options Notify lead nurse/doctor Contact Social Services Document results Scenario 4 Wash and glove hands Visual assessment Do not disturb Verify Call Light/Bed Safety precautions Document results Scenario 5 Assess for bowel sounds Encourage fluids/fiber/ambulation Evaluate patient understanding Attain fluids/fiber diet and assisted ambulation Document results 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, PaO 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 f - ANSWER Educational Needs Increased acuity Health Change Increased acuity LOC Normal acuity Pain Level Increased acuity Safety Increased acuity Richard Dominec - ANSWER Physiological Acute Pain True Bleeding False Chronic Pain False Constipation False
Knowledge Deficit True Nutrition True Risk for Infection True Skin integrity at risk True Love and Belonging Compromised Family Coping False Fear/Anxiety True Robert Domenic Scenario 1 After two hours, Mr. Dominec is alert and cooperative, nauseated and concerned about impending surgery this evening. His partner is at the bedside asking, "how much longer will he have to wait until taken to surgery?" Scenario 2 Mr. Dominec had his surgical procedure and is doing great. It is now the second day post op and he is given discharge information. His partner is not with him at this time but will arrive soon to facilitate his discharge home. Scenario 3 Mr. Dominec is waiting for his partner to arrive to take him home and you notice he has a dry unproductive cough and trouble splinting with a pillow at his operative site. You take his vital signs which are: Temp 101.3, Pulse 88, Resp 24, B/P 116/84. Scenario 4 Mr. Dominec decides he does not want to see Infectious Disease doctor about his new cough. He chooses to go home and see the doctor tomorrow in his office. He states, "Thi - ANSWER Scenario 1 Perform full assessment and provide anti-nausea medicine. Provide comfort in pre-surgical room Mr. Dominec. Check surgical consent for correct procedure and make sure operative site in marked. Inform his partner that everything is being done to keep him comfortable. Scenario 2 Educate about recovery from appendectomy and care to wound. Discuss his understanding about the plan of care. Discuss follow up with his doctor. Offer assistance in providing more information about treatment options for newly diagnosed AIDS patients. Determine from medical record if partner is aware of his recent AIDS diagnosis. Scenario 3 You discuss this cough with Mr. Dominec to determine how long he has had it.
Anxiety True Deficient Knowledge True Fall, Risk for True Grieving False Impaired Home Maintenance Management r/t Client or Family False Peripheral Neurovascular Dysfunction False Esteem Decisional Conflict True Deficient Diversional Activity False Disturbed Body True Hopelessness False Kathy Gestalt Scenario 1 Ms. Gestalt is second day post-op and has requested to get out of bed and to ambulate to bathroom. Scenario 2 Ms. Gestalt is now complaining of fever and chills. Scenario 3 After 24 hours, Ms. Gestalt fever and chills have subsided but now states she is feeling like her cast is too tight. Scenario 4 Ms. Gestalt capillary refilling is now 6 secs below cast site, extremity is swollen and cold to the touch. Scenario 5 You enter room and find Ms. Gestalt crying because she has just learned her medical insurance has lapsed and she is already two months behind on her car payments. - ANSWER Scenario 1 Check pedal capillary refill Educate patient Evaluate understanding Adjust crutches Assist patient out of bed Scenario 2 Wash and glove hands Vital assessment Administer antipyretic meds
Verify call light/bed safety precautions Document results/findings Scenario 3 Inspect cast site Assess toe movement and capillary refilling Notify doctor if condition is abnormal Document Results/Findings Scenario 4 Elevate Extremity Assess pain Educate patient regarding condition Notify lead nurse/doctor Retrieve cast removal tool Scenario 5 Use therapeutic communication/Active Listening Notify lead nurse/doctor Consult Social Service Evaluation patient after consult Document Results 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 - ANSWER Educational Needs Increased acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Increased acuity Psychological Needs Increased acuity Sensorium Normal acuity Robert Sturgess - ANSWER Physiological Bleeding, Risk for False Chronic Pain True Constipation, Risk for True Decreased Cardio Tissue Perfusion False Imbalanced Nutrition True Impaired Skin Integrity False
