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Swift River Med Surg Clinical Questions
& Answers
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 Fall Risk Increased Health Change Increased Pain Level Increased Psychological Needs Normal Sensorium Normal 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 Fall Risk Increased Health Change Increased Pain Level Increased Psychological Needs Normal Sensorium Normal 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%. - ANSWER Educational Needs Increased Health Change Increased LOC Normal Pain Level Normal Psychological Needs Normal Safety Increased
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 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%. - ANSWER Pain, Acute Physical Mobility, Impaired Skin integrity, impaired Knowledge Deficit Disturbed Body Image 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 Acute Pain Electrolyte Imbalance, Risk for Impaired Comfort Deficient Knowledge Fall, Risk for Infection, Risk for Linda Pittmon a 74 -year old female patient who is a noncompliant diabetic, and frequently stays at the local homeless shelter. She has been admitted to the floor with complaints of numbness in her right foot and ankle. Mrs. Pittmon states she has had numbness for years but "now I can't feel it at all, and my toes don't look the right color.". - ANSWER Disturbed body image Ineffective health maintenance Risk for malnutrition Impaired tissue integrity Risk for physical injury Self-care deficit
Ms. Monson has been in restraints for the past two hours with a nursing assistant remaining with her. You arrive in room to check on her, after washing hands. - ANSWER Employ therapeutic communication: present reality Release restraints/full range of motion Reapply restraints Perform circulatory evaluation Document results Lithia Monson Scenario 4 After 3 hours, Ms. Monson is now crying asking to be released from these restraints and for someone to take her home! - ANSWER Use therapeutic communication/active listening Attempt to orient to person, place, and time Perform circulatory evaluation Offer nutrition and/ or toileting Document results Lithia Monson Scenario 5 In reassessing Ms. Monson, her vital signs are: BP -106/82, Temp-98.2, P-106, RR-18, SaO2-88. - ANSWER Check monitor Apply nasal cannula oxygen Vital sign re-assessment Notify lead nurse/doctor Remain with Patient Virginia Smith Scenario 1 Mrs. Smith shares with you that even though she signed the operative consent she was not sure if this was the right surgical procedure for her. Her husband who is present states, "I thought it was just a lumpectomy she was having this morning." - ANSWER Ask patient to explain to you what procedure she was expecting to have this morning. If patient statement differs from the surgical consent she has signed, notify surgeon immediately. Stay with patient for surgeon's arrival to explain intended surgical procedure Contact head nurse or supervisor in the OR to evaluate new situation Procedure is canceled for the day and rescheduled later allowing for new consent. Virginia Smith Scenario 2 It is now two weeks later; Mrs. Smith has returned. You question her while reviewing her operative consent and determine that everything is correct. She receives the pre-op medication. Her husband and children remain with her in the surgical holding area awaiting transport to the OR. - ANSWER Therapeutic communication Validate NPO Status Encourage to ambulate with assistance to void if needed. Connect telemetry Provide a few chairs if possible for her family to also be comfortable
Virginia Smith Scenario 3 Mrs. Smith's surgery has now ended. You now arrive in the recovery unit one hour post- surgery and you are told that the surgery went well. Her chart reports she was extubated upon arrival to the recovery area, received three units (3000 mL) of fluid, receiving O2 @ 4L via nasal cannula, has Foley Catheter in place draining QS clear yellow urine, responds to verbal stimulation, chest dressing in place remains dry and intact, and has just received a small dose of IV morphine for pain. Vital signs are: B/P 112/78, temp. 97.4, Resp 16 and Pulse Ox 94% - ANSWER Vital signs taken by automatic B/P cuff q 15 minutes. Complete assessment. Talk with her stating surgery is over and she did great. Allow husband to make a quick one-minute visit. Document and prepare to transfer to Surgical ICU. Virginia Smith Scenario 4 You are about to call the Surgical ICU and give report. What order are you providing the information to the receiving nurse? - ANSWER Provide Operative summary of type of procedure, IV fluid and pain status. Present health assessment including B/P and LOC and dressing. Report current urinary output quantify per hour and color of urine Request time she can arrive and staff to help with transfer Explain to her family and provide contact information.Letting the family know assures them so they can be ready to provide support if needed. Family concern comes after patient care. Virginia Smith Scenario 5 You are the now the Surgical ICU nurse assigned to her. She has just been transported from recovery. List the nursing care order. - ANSWER Full assessment of patient. Provide for physical and thermal comfort. Therapeutic communication. Begin post op education for day one. Notify family as to when they may come and visit. Estelle Hatcher Scenario 1 Ms. Hatcher is second day post-op and has a nasogastric tube set to gravity drainage only. She presses the call light with questions about who her nurse will be and her NG- tube. - ANSWER Introduce Yourself/Identify Patient Full Assessment Educate Patient Evaluate Understanding Provide Comfort 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 - ANSWER Educational Needs Increased Fall Risk Increased
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. - ANSWER Wash/Glove Hands Inspect Pain Location Check Proper Positioning Verify Call Light/Bed Safety precautions Notify Doctor (for possible Removal) Estelle Hatcher Scenario 3 Dr. Brown gives orders to remove nasogastric tube set to gravity and to begin a clear liquid diet. - ANSWER Educate patient of procedure Evaluate Understanding Remove NG-Tube Order a new clear liquid diet Document Results Estelle Hatcher Scenario 4 Mrs. Hatcher appears restless, diaphoretic and calls the nurse for help. Upon entering the room, what is the appropriate order of events for the nurse to take? - ANSWER Wash/Glove Hands Full Assessment Encourage Incentive Spirometry Verify Call Light/Bed Safety precautions Document Results Estelle Hatcher Scenario 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 Use therapeutic communication/Active Listening Educate Patient Evaluate Understanding Verify Call Light/Bed Safety precautions Document Results Linda Pittmon Scenario 1 Patient presents to the unit c/o numbness in the right foot and ankle and toes "not looking the right color". All 5 toes on the right foot are necrotic, absent pedal pulses, skin cold to touch, appearance dry, cracked and black up to mid-calf. Foul odor noted with green drainage coming from toenail beds. Doctor orders: 1. IV Fluids 0.9% NS peripheral line at 100 mL/hr. 2. CBC, CMP, Blood culture x 2, Hgb A1C 3. CT Scan of right lower leg 4. Blood lab tests 5. Levofloxacin (Levaquin) 750 mg IV q 24 hours - ANSWER Wash hands and don gloves. Obtain blood for laboratory testing and blood culture # 1. Obtain blood from secondary site for blood culture #2. Initiate IV fluids to peripheral site.
Administer levofloxacin as ordered. Linda Pittmon Scenario 2 Patient speaking incoherently and is exhibiting rapid eye movement with a blank stare. An empty syringe is noted in the bed. Patient does respond partially to commands. Brisk peripheral reflexes, Eyes equal, round, dilated. - ANSWER Ask the patient if she knows where the syringe came from and what was in the syringe. Assess the vital signs and perform a neurological focused assessment. Place the syringe in a biohazard bag and place a patient identification label on bag. Notify the charge nurse and house supervisor of the syringe found in bed. Notify the physician of assessment findings and await further orders. Linda Pittmon Scenario 3 8 hours later, patient is fidgety and is observed picking at her skin and clothes. The patient states "I am sick to my stomach and feel like I have bugs crawling all over me!!!"
- ANSWER Assess vital signs and perform head to toe assessment. Therapeutic communication with patient. Call Healthcare Provider for change in health status and receive orders for anxiety medication. Prescribed medication for anxiety must be administered. Assess for therapeutic response to medications. Linda Pittmon Scenario 4 Surgery called to the unit that Ms. Pittmon is scheduled at 1300 for a Below the Knee amputation. - ANSWER Ask Mrs. Pittmon if she remembers the conversation with the physician and if she has any further questions that need to be addressed. Perform pre op checklist. Ensure signed consents are on the chart. Ensure type and cross match for blood products is complete and results are in electronic medical record Have IV antibiotics available to administer when surgery calls for the patient to be transferred to pre op area. Linda Pittmon Scenario 5 Post op day 3 time for dressing change stump. Patient states pain has been managed throughout the night. Pulses above the stump are palpable at 2+, Skin is warm and dry. Patient states she has noted some "toe pain" but that it has been < 3 on a scale of 1-10.
- ANSWER Pre-medicate for pain with prescribed medication. Don clean gloves to remove old dressing. Monitor neurovascular status assessing skin color, temperature, sensation, pulses above amputation. Don 2nd set of clean gloves to provide stump care. The wound has been sutured and is not an open wound/stump. Elevate stump and rewrap with a dry clean dressing. Sarah Kathryn Horton Scenario 1
the road working with a jackhammer. Ms. Horton hears the jackhammer and then screams and dives to the floor. - ANSWER Assess Ms. Horton's orientation status. Use therapeutic communication to re-orient and provide reassurance. Assist Ms. Horton back into the wheelchair. Escort patient to the ER for a physical and psychological evaluation. Provide report to ER nurse. Ann Rails Scenario 1 You enter patient's room. After washing and gloving hands, you then identify yourself and the patient, Ann Rails. You notice she is crying and is expressing fear that she "will always have this pain and numbness" and she doesn't think she can cope. - ANSWER Use therapeutic communication/Active Listening Educate patient regarding patient care Evaluate patient learning Place call light and check bed for safety Document results and findings Ann Rails Scenario 2 Ms. Rails was medicated with hydrocodone 5 mg PO two hours ago and is now complaining of pain (8/10 pain scale). - ANSWER Wash and glove hands Assess Provide comfort measures Notify doctor Document results and findings Ann Rails Scenario 3 Ms. Rails shares with you her fear of being discharged home to an abusive husband. - ANSWER Listen to patient concerns Reassure patient of options Notify lead nurse/doctor Contact Social Services Document results Ann Rails Scenario 4 Upon entering the room, you find Ms. Rails sleeping. She has received a dose of Hydrocodone for PRN pain 20 minutes ago. - ANSWER Wash and glove hands Visual assessment Do not disturb Verify Call Light/Bed Safety precautions Document results Ann Rails Scenario 5 Ms. Rails states that she has not had a bowel movement (BM) in the past two days. - ANSWER Assess for bowel sounds Encourage fluids/fiber/ambulation Evaluate patient understanding
Attain fluids/fiber diet and assisted ambulation Document results Karen Cole, 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. 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. - ANSWER Educational needs increased Fall risk normal Health change increased Pain level normal Psychological need normal Sensorium normal 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 PaO (hypoxemia) and increasing CO2 (Hypercapnia). Mr. Thomason is anxious and is obviously worsened from the shift before in overall condition. - ANSWER Impaired Gas Exchange Ineffective airway clearance Anxiety/ fear Mary Barkley, 74y/o female has been admitted to your floor with a respiratory infection and she has tested positive for COVID19. She resides in an assisted living facility which has seen four deaths related to COVID19. She is exhibiting the same initial signs and symptoms as the other patients and her primary care provider would like to start aggressively treating her. She is running a low-grade fever 99.8 and has a sore scratchy throat which is causing an unproductive cough. She also is complaining of chills, muscle pain and headache. She is an at-risk patient because of her age. She also suffers from Lupus and is already taking Hydroxychloroquine, a first-line lupus therapy, but there is no conclusive evidence of its benefits for coronavirus yet. She is very fearful and is requesting to see her family. She states that she does not want to die alone. - ANSWER Educational needs increased Fall risk normal Health change increased Neurological normal Pain level increased Psychological need increased
interstitial infiltrates in all lobes. Recent blood gases demonstrate falling PaO (hypoxemia) and increasing CO2 (Hypercapnia). Mr. Thomason is anxious and is obviously worsened from the shift before in overall condition. - ANSWER
