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Swift River Med-Surg Questions &
Answers
Carlos Mancia 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 Fall Risk: Increased Health Change: Increased Pain Level: Normal Psychological Needs: Increased Sensorium: Normal Physiological- Dysfunctional Gastrointestinal Motility: False Electrolyte Imbalance: False Fatigue: True Impaired Gas Exchange: True Impaired Mobility: False Ineffective Airway Clearance: True Esteem- Decisional Conflict: False Noncompliance: True Safety- Anxiety: True Deficient Knowledge: True Fall, Risk for: True Fear: True Hypothermia: False Impaired Home Maintenance Management: False Self-Actualization- Readiness for Self-Care Enhancement: True Spiritual Distress: False
Love and Belonging- Chronic Sorrow: False Social Isolation, Risk for: True Jody Rush Jody Rush, 20 y/o female, admitted for right femur fracture status post skiing accident. She is in a traction splint, and will be going for surgical repair today. Vital signs are BP 120/62 P 88 R 20 T 98.9 F, 37.2 C, PaO2 99. She has been in a lot of pain, and has been receiving 25 mcg IVP, q2 hours Fentanyl for pain. She was nauseated after her last Fentanyl dose, and the Dr. Ordered an additional 4mg IVP, Zofran. She has a history of exercise induced asthma, and uses a rescue inhaler, Albuterol. Her parents are on their way; they are flying in today. She was on a ski trip with some of her friends from college; her best friend has been camped out with her. We were able to get her on a bed pan earlier, but it took a lot of work. We just received an order for a foley catheter. There was some concern that she may have sustained a head injury as she has an abrasion to her forehead, but she denies ever losing - ANSWER Educational Needs: Increased Fall Risk: Increased Health Change: Increased Neurological: Increased Pain Level: Normal Psychological Needs: Normal Physiological- Acute Pain: True Bleeding, Risk for: True Impaired Mobility, Risk for: True Nausea: True Safety- Deficient Knowledge: True Grieving: False Peripheral Neurovascular Dysfunction: False Mary Barkley 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
Scenario 1 Jody is back from the OR resting quietly. They performed an open reduction internal fixation (ORIF) with two plates and eight screws. Her dressing is dry and intact. She has good sensation in her operative leg, and can wiggle her toes. Her VS are stable, and her Foley is draining clear urine. She has an 18-gauge IV Cath to left forearm that anesthesia started in the OR. The IV is RL running at 125ml/hr. She has Ancef, 1 gm ordered. The nurse is trying to get her to use her incentive spirometer. Scenario 2 Jody's parents arrive and are visiting with her. The patients mom is concerned that Jody does not seem herself, and is a little confused. The nurse explains that she is receiving Fentanyl for pain, and is not yet fully alert from the anesthesia. Vital signs are BP 113/60 P 76 R 18 PaO2 96 T 99.1 F, 37.3 C Mary Barkley Scenario 1 Right after admission the nurse finds her walking down the hall trying to leave. Redirect the patient back to her room. Scenario 2 Mrs. Barkley is becoming more adamant about leaving while her physical condition continues to deteriorate. Her Temp is 100.8 BP 100/62 P 92 R 21 SpaO2 91. The nurse auscultates fine crackles in her lungs bilaterally, but her sputum is clear. She is oriented x3 but at times seems to be talking to someone in the room when no one is present. She told the nurse that she does not want a breathing tube, but her family has told the nurse by phone that they want every effort done to save her. She pulled out her IV and it will need to be restarted for her IV cipro dose that is due now. The nurse has another high acuity admission that has just arrived from the ER. Scenario 3 Ms. Barkley continues to deteriorate and is shouting for her family. She is disoriented and believ - ANSWER Scenario 1 -Have patient put on a mask -Wash hands and don PPE -Use therapeutic communication to comfort patient -Guide her back to her room while teaching her that her isolation is to protect others including her family. -Set her up with a video chat with her family. Scenario 2 I-nitiate O2 at 2L nasal-cannula. -Alert the charge nurse that Ms. Barkley is deteriorating and you need to remain with her. Ask the charge nurse to assign another nurse to the new admission.
-Have an aide sit with Ms. Barkley while you obtain the IV supplies, and notify the Healthcare Provider of her declining condition. -Wash hands and dawn PPE and restart IV and secure with gauze wrap. -Secure sitter to stay with Ms. Barkley after the insertion of the new IV. Scenario 3 -Contact RT for a stat CPAP trial. -Obtain telemetry set-up and take to patients room. -Ask PCT to secure mask better, and inform her that there is no replacement for her. -Don PPE and have PCT assist with connecting the patient to Telemetry. -Assist RT to initiate CPAP trial. Scenario 4 -Call rapid response, RRT. -Continue to assist RT in ventilation. -Give SBAR to RRT upon arrival. -Call for crash-cart for possible intubation. -Ensure documentation of time and events of RRT. Scenario 5 -Encourage Healthcare Provider to consider intubation in the absence of signed DNR. -Offer to contact family for Healthcare Provider. -Contact Assisted Living facility (ALF) to see if patient has an Advanced Directive in place declining. -Notify the Healthcare Provider of absence of Advanced Directive and families request to intubate. -Assist with intubation, and logistics of managing the critical patient on the floor. Wight Goodman Scenario 1 Mr. Goodman has been scheduled for surgery to repair a supraorbital rim fracture, but he is very concerned about any scaring that may affect his appearance. He is alert and oriented times five, and has signed the surgical consent. The nurse notices a small amount of blood coming from the patient's nose. He does not remember his nose bleeding initially or in the ER. VS BP140/82 P74 R 20 T 98.7 F, 37.1 C. Scenario 2 The blood from the nose was positive for CSF. An MRI is ordered, and reveals a small Orbital roof fracture. The neurosurgeon is consulted. The maxillofacial surgeon will repair the suborbital rim fracture first, and the neurosurgeon will monitor the patient postoperatively as well as be available to assist if the orbital roof fracture becomes unstable. IV antibiotics are ordered to be administered ASAP. The patient will need to sign another surgical consent for potential neurosurg - ANSWER Scenario 1 -Wash hands and assess -Complete Neurological assessment
Jody is more awake, but has become anxious. Her mother is very concerned and - ANSWER Scenario 1 -Wash hands and provide patient privacy -Complete full assessment, to include capillary refill and pedal pulses -Medicate as needed for pain -Encourage positioning, turning, coughing, and deep breathing post-operatively. Initiate incentive spirometry, and then hourly there after -Orient friend in room to provide assistance with incentive spirometry to patient hourly Scenario 2 -Complete Neuro assessment -Educate Jody's parents to injury and surgical repair -Offer full AM bath, and ask parents if they would like to remain in the room or step out -Log-roll patient to complete full assessment of patients back, and to complete bath -Ensure Foley is draining, and the IV is still patent Scenario 3 -Inform patient and family that new orders have been given to rule out further complications -Draw stat D-dimer blood test -Obtain additional support to transfer patient to radiology -Ask parents to remain in the room -Accompany patient and transfer patient to Radiology Scenario 4 -Start O2 100% non-rebreather mask -Provide SBAR to the RRT upon arrival -Page Surgeon stat to radiology -Prepare for Heparin administration -Assist RRT as needed and document Scenario 5 -Assist and support the continuous CPR during transport to the ICU -Alert ICU of impending emergent arrival, and stat ECMO -Following patient arrival to ICU, inform family of what has happened -Provide emotional support; remain with patients family, offer to call family or Chaplain, and other way you can be of assistance -Ask Charge nurse for assistance with other patients while you remain with the family, as the patient's condition is unknown Scenario 3 Before entering Carlos Mancia room to administer his antipyretic medication for his recent temp of 101. Scenario 4
The sister of Mr. Mancia calls from home to speak with you. She shares her concerns about the patient's wife who is now coughing and having night sweats. Scenario 5 Mr. Mancia is holding a Catholic Rosary in his 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 translator -Wash Hands -Put on gown and mask -Don Gloves -Administer antipyretic medication Scenario 4 -Educate caller regarding HIPAA -Evaluate caller understanding -Refer caller to contact health department -Notify doctor -Document conversation Scenario 5 -Obtain translator -Use therapeutic communication/Active Listening -Educate patient -Evaluate learning -Document teaching moment Robert Sturgess 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
Mr. Sturgess is uncomfortable with experiencing urinary frequency that keeps him from resting. Scenario 5 Mr. Sturgess is now declining, and family members are requesting to remain in room past normal visiting hours. - ANSWER Scenario 1 -Wash and glove hands -Full assessment -Seek clarification -Check PRN pain order -Verify call light/bed safety precautions Scenario 2 -Full assessment -Educate patient regarding changes to POC -Place patient on PCA pump -Observe closely first hour -Perform pain re-assessment Scenario 3 -Use therapeutic communication/active listening -Educate patient/family -Notify doctor -Contact Social Services -Report and document results Scenario 4 -Use therapeutic communication/Active Listening -Notify doctor for Foley catheter -Education of Foley Cath Procedure -Insert Foley catheter -Document Procedure Scenario 5 -Allow family to remain -Full assessment -Provide comfort and pain measures -Pain re-assessment -Document results Ronald Burgundy A new graduate nurse receives a call from the hospital telling them to report to the ER immediately for a disaster. The nurse arrives and sees a tent is being erected as a
triage area, and ambulances are lined up delivering trauma patients. The nurse identifies self to the nurse triaging patients and is directed to trauma room 4. When you arrive to room 4, you are told to assume the care for the patient and get ready to transport them to the floor ASAP. The patient is awake, alert, and oriented. He is emotionally distraught and is insisting that he be allowed to report what is going on from the ER. He is a local TV news reporter that was filming an event at the county fair when there was an explosion. The patient is awake alert and oriented. He is emotionally distraught, and is insisting that he be allowed to report what is going on from the ED. He has partial thickness burns to his left arm and the - ANSWER Physiological- Acute Pain: True Bleeding: True Impaired comfort: True Nausea: False Safety- Deficient knowledge: True Fall, risk for: True Grieving: False Ronald Burgundy Scenario 1 The charge nurse tells you to get the Mr. Burgundy to the hallway because six more patients are inbound, and we need to clear out our trauma-bays. In the interim, start an IV and start infusing Ringers Lactate. Put the patient on O2 NC and Fentanyl 25mcg IVP for pain. Scenario 2 When she moves him to the hallway, Mr. Burgundy begins yelling at you "Do you know who I am, I demand a room! Where is my camera man!! I need to be reporting!" When the HCP realizes who he is, he tells the nurse to move the patient in the treatment room down the hall and put Mr. Burgundy in there. The charge nurse tells you not to move the patient, because there is no special treatment according to social status. Scenario 3 The nurse observes an elderly lady who is crying and has not been taken care of yet. The charge nurse asks you to assume the patient's nursing care. The patient is asking you where her son is, - ANSWER Scenario 1 -Explain to the patient that he is now considered stable, you are taking him to the hallway, and he will be admitted to an impatient room within a few hours -Ensure there is a full O2 tank on the gurney, place patient on Nasal Cannula -Start an IV -Medicate for pain -Advise patient not to get up and walk on his own Scenario 2
Scenario 5 When completing the shift change neuro check, you notice the patient's left pupil is sluggish. You also notice the patient is more difficult to orient. - ANSWER Scenario 1 -Perform neuro assess -Reorient Patient to person, place, & time -Assess for fall risk -Offer nutrition/toilet -Discuss effectiveness of sitter Scenario 2 -Complete neuro checks as ordered -Discuss and determine sitter availability -Check on patient/sitter hourly -Advise sitter to notify nurse when leaving the room -Determine when a hospital provided sitter will be necessary Scenario 3 -Reassess patient -Ensure patients is positioned in bed properly -Discuss with sitter that patient needs continual observation -Discuss with family sitter if there are any other family members who can help with monitoring Lithia -Document and contact nursing supervisor/Charge nurse Scenario 4 -Complete full assessment, to include neuro -Use therapeutic communication/active listening -Attempt to orient to person, place, and time -Offer nutrition and/ or toileting -Ensure bed is in lowest position, and rails are in place Scenario 5 -Notify HCP of neuro findings -Notify charge nurse of patient's deteriorating condition -Begin q15 minute neuro checks -Have patient remain in bed, head elevated 30 degrees -Ensure IV is patent Lithia Monson 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 - ANSWER Physiological- Bleeding, Risk for: True Decreased Cardiac/perfusion: False Imbalanced Nutrition: True Nausea: False Self-Care Deficit: True Shock, Risk for: False Safety- Acute Confusion: True Fall, risk for: True Peripheral Neurovascular Dysfunction: False Sleep deprivation: False Love and belonging- Compromised Family Coping: False Failure to Thrive: True Nathaniel Gonzalez , a 58-year-old male patient presents to the ER CO CP 10/10. He is pale, weak, diaphoretic, and appears anxious. He has a history of well controlled GERD with over- the-counter Tagamet (Cimetidine), and Tums. He also has a history of hypertension and takes Tenormin (Atenolol) and Atorvastatin (Lipitor). He was recently treated for a URI with a Z pack, prednisone, and Motrin for pain. BP 154/89, P 94 F, R 22, T 98.3F, SaO 95% on room air. The patient was placed on 2 L O2 NC, EKG monitoring to include a 12 lead, Pulse Oximeter. IV NS is started, and lab work is sent. ASA is held but morphine 4 mg was given after his GI cocktail. A GI cocktail was administered, and the patient stated that it decreased his pain to a 6/10. - ANSWER Physiological- Acute pain: True Bleeding Risk for: False Safety- Deficient knowledge: True Fall, risk for: True Infection, risk for: False Nathaniel Gonzalez Scenario 1 Mr. Gonzalez has been admitted to the floor to determine that his chest pain is not related to a cardiac event. The ER nurse reports that his cardiac enzymes were borderline, (Troponin?, CK/CKMB?) and the GI cocktail given in the ER did relieve his
-Assess patients' pain and rule out cardiac pain. -If gastric reflux is suspected administer PRN antacids (GI cocktail) -If cardiac is suspected call the provider and the rapid response team. -Assess t Paul Greer is a 57 y/o who has been admitted for a radical prostatectomy. He was recently diagnosed with stage III prostate cancer. His original lymph node biopsy was negative. He has a history of hypertension and is not compliant with medication. Until the recent diagnosis of cancer, the patient had only seen a physician once in the last ten years. He has a 20-year one pack history of smoking. However, he quit three years ago when he remarried; he and his wife have a nine-month-old baby. His difficulty voiding finally motivated him to seek care. - ANSWER Physiological- Acute pain: False Impaired comfort: True Impaired mobility: False Safety- Deficient knowledge: True Fall, risk for: False Grieving: False Sexuality: True Paul Greer Scenario 1 Mr. Greer has just returned from surgery. The cancer was more advanced than they previously had thought so inguinal lymph nodes were removed. The surgeon believes that the surgery was successful but recommends the patient have chemotherapy and radiation postoperatively. The patient has a Foley catheter in place and is reporting 8/ incisional pain and he is asking why his throat is sore. VS: BP 158/90, HR 89, R 18, T 97.8 F. Scenario 2 Mr. Greer has just been visited by his wife. His wife tells the nurse that he seemed very distant and did not want to talk much. While assessing the patient, Mr. Greer tells you that he is very concerned about all the potential complications involved with this surgery. He is aware that he may not have an erection and may need depends for bladder incontinence. Scenario 3 The surgeon has just visited with Mr. Greer 2-days post op and has informed him that the ly - ANSWER Scenario 1 -Complete initial post-op assessment -Check patency of Foley catheter, urine color, and ensure it is secure to the patient's leg
-Medicate for pain -Explain to patient why his throat may be sore -Inform patient to not get out of bed without assistance and place call light in reach Scenario 2 -Tell the wife that you will speak to the husband, and this is apprehension is expected with this surgery/diagnosis. -Explain to Mr. Greer that it may take several days for healing, and he may have temporary incontinence, but it will resolve over time. -Teach the patient that there are several interventions for complications post- prostatectomy to include erectile dysfunction, post-op prostatectomies, and self-care involved with a foley catheter at home. -Evaluate patient's understanding of teaching -Continue to observe urine for hematuria and document findings Scenario 3 -Using therapeutic communication inform Mr. Greer that there are many treatment options, and not to leave until the HCP can come and speak with him -Contact HCP to determine when they are available to speak with the patient -Provide the patient with the time when HCP will come discuss options with him -Provide a diversional activity to pass the time while waiting on the HCP and inform wife that the HCP will be coming soon -When the HCP arrives, stay in the room to determine whether you can continue care with the patient Scenario 4 -Complete head-to-toe assessment while patient is on the floor. -Ensure patient privacy and call for help and assist patient to bed once help arrives -Complete secondary assessment once the patient is in bed focusing on complaint of pain resulting from the fall -Reinforce to the patient to not get out of bed -Notify HCP of fall, complete incident report Scenario 5 -Ask the patient if it is okay to discuss his care in fr
