All Swift River Medical-Surgical Room Cases, Solved! Graded! Updated Spring 2022; Distinction Level Assignment Has everything.

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Swift River Medical-Surgical cases All 2022. Ann Rails - Educational - Increased Fall Risk - Increased Health Change - Increased Pain - Increased Psychological Needs - Normal Sensorium - ... Normal Ann Rails - Acute pain Impaired comfort Impaired mobility Disturbed sensory perception Fall, risk for Peripheral neurovascular dysfunction Ann Rails - Scenario #1 Use therapeutic Educate pt. Evaluate pt. learning Place call light Document Scenario #2 Wash and glove hands Assess Provide comfort measures Notify doctor Document Scenario #3 Listen to pt. concerns Reassure pt. of options Notify lead nurse/doctor Contact Social Services Document Scenario #4 Wash and glove hands Visual assessment Do not disturb Verify Call Light Document Scenario #5 Assess for bowel sounds Encourage fluids/fiber/ambulation Evaluate pt. understanding Attain fluids/fiber diet Document Arthur Thomason - Educational - increased Health change - increased LOC - increased Pain - increased Psychological needs - increased Safety - increased Arthur Thomason - Impaired confort Impaired gas exchange Ineffective airway clearance Shock, risk for Anxiety/fear Failure to thrive, risk for Arthur Thomason - Scenario #1 Assess Replace O2 Use therapeutic Notify Dr. and charge nurse Scenario #2 Remind physician Explain to physician Assist physician Obtain recent Reassure pt. Scenario #3 Tap pt. Elevate HOB Call rapid response Start secondary Remain with pt. Scenario #4 Provide verbal report Emergency intubation Assume role Obtain pt. record Provide information Scenario #5 You explain that his condition You explain that he is receiving You have them remain with you You escort them with you You call his doctor Calvin Umbyuma - Educational - increased Fall Risk - normal Health Change - increased Pain - increased Psychological needs - normal Neurological - normal Calvin Umbyuma - Acute pain Deficient knowledge Calvin Umbyuma - Scenario #1 Place on respiratory isolation Ask Mr. U Obtain blood cultures Start IV Collect sputum culture Scenario#2 Wash hand, don PPE Explain to the visitor Respiratory assessment Explain to Mr. U Place signage on door Scenario #3 Ask pt. what he knows Ask pt. what his mother's Educate pt. Evaluate effectiveness Report findings Scenario #4 Pt. teaching Contact respiratory therapy Chest x-ray Western blot Bronchoscopy Scenario #5 Elevate HOB Initiate O2 at 4L Reassess VS Reevaluate amount of blood lost Contact HCP Cameron Daniels - Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - normal Neurological - normal Cameron Daniels - Acute pain Impaired mobility Deficient knowledge Fall, risk for Infection, risk for Cameron Daniels - Scenario #1 Give tylenol Start another IV Initiate bolus Request additional pain med Reasses temp in 1 hour Scenario #2 Sit at an eye level Teach Cameron Evaluate understanding Contact charge nurse Document pt's statements Scenario #3 Provide emotional support Assure pt. Explain to pt. Stress importance Inform pt. Scenario #4 Make sure accurate wt. Explain reason for medication Tell the mother that you understand Tell the mother that visitors are welcome Be honest with Cameron Scenario #5 Assess pt. Perform rapid assessment Ask pt. Inform charge nurse Call local law enforcement Chanthavy Chhet - Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Neurological - normal Chanthavy Chhet - Acute pain Impaired mobility, risk for Nausea Cultural competence Deficient knowledge Impaired verbal communication Chanthavy Chhet - Scenario #1 Obtain translator Initiate IV Begin fluid and electrolyte Administer IV ABX Consult with MD Scenario #2 What is going on? We need to stop the bleeding Tell me where you are Who were you talking to? What were the voices telling you? Scenario #3 Attempt to establish rapport Notify HCP of findings Attempt to restart IV Contact dietary Obtain a sitter Remove potential harmful objects Scenario #4 Delay insertion of IV Contact HCP Contact CC's uncle Request the uncle come Request the uncle participates Scenario #5 Provide one-to-one Initiate anti-psychotic meds Ensure family member Reassess environment Initiate continuous observation Clement Hall - Educational - increased Fall Risk - increased Health Change - increased Neurological - normal Pain - increased Psychological needs - normal Clement Hall - Acute pain Impaired mobility, risk for Fluid & electrolyte imbalance, risk for Infection Clement Hal - Scenario #1 Contact isolation Administer pain meds Initiate IV Ask pt. Document physical findings Scenario #2 Explain the need Elevate HOB Measure nose to ear Have pt. swallow Check placement Scenario #3 Remind pt. Reassess pt. Obtain an order Teach pt. to avoid Teach pt. to apply Scenario #4 Assess pain Asminister morphine NG tube to LIS Call for triple lumen Address concerns Scenario #5 Therapeutic communication Pt. teaching Evaluate learning Make referral Dietary consult Dana Fitzgerald - Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - normal Neurological - normal Dana Fitzgerald - Deficient knowledge Grieving, risk for Dana Fitzgerald - Scenario #1 Sit with the pt. Reinforce provider teaching Assess family support system Reassure the pt. Ask the pt. Scenario #2 Head-to-toe assessment Inspect catheter Teach pt. Instruct pt. Ask the charge nurse Scenario #3 Teach the pt. Explain to the pt. Administer pain meds Tell the pt. Have the pt. ambulate Scenario #4 Inspect pt's abdomen Auscultate Percuss & palpate Contact provider Tell husband & pt. Scenario #5 Inform the pt. Provide pt. privacy Lubricate tip of enema Squeeze the contents Have the pt. lay on their side Don Johnson - Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Neurological - normal Don Johnson - Acute pain Altered body image, risk for Audiology changes, risk for Fluid & electrolyte imbalance, risk for PTSD, risk for Infection, risk for Don Johnson - Scenario #1 Complete full assessment Insert foley Initiate IV Apply Silvadene Contact HCP Scenario #2 Reassess lung sounds Empty foley bag Administer pain meds Notify HCP Document Scenario #3 Elevate HOB Assess pt's sputum Reassure the pt. Assure the pt. Contact respiratory therapy Scenario #4 Obtain doppler pulse Adjust rate of IV Ask for available tech Change dressing Determine if the pt. Scenario #5 Obtain bear hugger Explain to the pt. Notify nursing supervisor Contact nutritionist Allow visitors to enter Dotty Hamilton - Educational - increased Fall Risk - normal Health Change - normal Pain - normal Psychological Needs - increased Neurological - normal Dotty Hamilton - Bleeding, risk for Impaired comfort, risk for Deficient knowledge Infection, risk for Dotty Hamilton - Scenario #1 Contact surgeon Complete pre-op Ensure surgical consents Check to see Pt. teaching Scenario #2 Wash hands Complete full assessment Check wound sites Use therapeutic Encourage first IS Scenario #3 Reassure & communicate Check blood glucose Administer ABX Encourage aggressive IS Start PCA pump Scenario #4 Reassure pt. Complete full pt. assessment Assess whether or not Obtain labs Notify HCP Scenario #5 Complete full assessment Place pt. on telemetry Check foley Assist anesthesia Explain to pt. Scenario #6 Have family step out Bring the family in Offer to the family Contact funeral home Ask nursing manager Glenn Massey - Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - normal Neurological - normal Glenn Massey - Acute pain Impaired mobility, risk for Nausea, risk for Deficient knowledge Glenn Massey - Scenario #1 Ensure room was cleaned Disinfect call light Clean and obtain IV pole Obtain burn sheets Notify infection control nurse Scenario #2 Obtain VS Initial assessment Administer pain meds Educate pt. Check pt's chart Scenario #3 Hand hygiene Set up supplies Apply clean gloves Gently peel off Clean wound site Apply new dressing Scenario #4 Notify HCP Inform pt. Initiate cardiac telemetry Give 1L NS Empty foley Scenario #5 Explore why pt. Educate pt. Evaluate pt's understanding Contact social services Involve family Hannah Knox - Educational- increased Fall Risk - increased Health Change - increased Pain - increased PsychologicL Needs - increased Neurological - normal Hannah Knox - Chronic pain Impaired comfort Deficient knowledge Fear of death Gas exchange, risk for Infection, fisk for Hannah Knox - Scenario #1 Full assessment Contact IV team Contact HCP Set up PCA Contact social services Scenario #2 Administer ABX & start morphine Contact hospice/social work Place pt. on continuous pulse ox Reassess effectiveness Document Scenario #3 Reassess VS & elevate HOB Continue to provide Seek clarification Call respiratory therapy Provide emotional support Scenario #4 Full assessment Place pt. on 100% non-rebreather Review PCA pump history DNR armband Discuss with HCP Scenario #5 Contact HCP Contact chaplain Take pt's family Prepare Mrs. Knox's body Notify social services Hildegard Lowe - Educational - increased Fall Risk - increased Health Change - increased Pain - normal Psychological Needs - normal Neurological - normal Hildegard Lowe - Impaired mobility, risk for Deficient knowledge Impaired gas exchange, risk for Peripheral neurovascular dysfunction, risk for Risk for infection Ineffective breathing pattern Hildegard Lowe - Scenario #1 Reposition HOB to semi-fowler's Increase supplemental O2 Orient pt. Initiate IS treatment Retake VS Scenario #2 WBC Magnesium RBC Hemoglobin BUN Scenario #3 Stop infusion Don gloves Inspect site Collect supplies Remove IV & document Scenario #4 Have secretary Review current Discuss the policy Ask Hildegard Document teaching Talk to daughter Scenario #5 Don gloves & assist pt. Assess stool Assist pt. to bed Anticipate need Call the physician Place pt. on enteric Janene Whitmore - Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Neurological - normal Janene Whitmore - Acute pain Bleeding Impaired comfort Deficient knowledge Infection, risk for Janene Whitmore - Scenario #1 Explain to pt. Medicate pt. Initiate IV Put an arm band Ask pt. Scenario #2 Explain to Mrs. Whitmore Inform pt. Explain to pt. Reassure pt. Ask Mrs. Whitmore Scenario #3 Contact charge nurse Contact hospital liaison Inform pt. Inform admitting physician Document Scenario #4 Ask pt. Administer Epoetin Pt. teaching Administer diluted iron Reassess pt. Scenario #5 Remind surgeon & staff Notify HIPAA Notify charge nurse Suggest Introduce hospital liaison Jody Rush - Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - normal Neurological - normal Jody Rush - Acute pain Bleeding, risk for Impaired mobility, risk for Nausea Deficient knowledge Jody Rush - Scenario #1 Wash hands Complete full assessment Medicate Encourage positioning Orient friend Scenario #2 Complete neuro Educate Jody's parents Offer full AM bath Log roll pt. Ensure foley is draining Scenario #3 Inform pt. & family Draw stat D-Dimer Obtain additional support Ask parents Accompany pt. Scenario #4 Start O2 100% Provide SBAR Page surgeon STAT Prepare for heparin Assist RRT Scenario #5 Assist & support Alert ICU Following pt. arrival Provide emotional support Ask charge nurse John Davis - Educational - increased Fall Risk - normal Health Change - increased Pain - normal Psychological Needs - normal Neurological - normal John Davis - Deficient knowledge John Davis - Scenario #1 Offer pt. a urinal Perform post-op Assist pt. Tell pt. Ensure side rails Scenario #2 Assess large dressing site Administer pain meds Assess dressing supply Assess pt's need Document Scenario #3 Restart new IV Administer nausea med Assess for contraindications Weight the pt. Take VS & provide pt. teaching Scenario #4 Complete full assessment Apply clean dressing Encourage pt. Continue to encourage Document & inform Scenario #5 Assess pt's concerns Teach pt. Make referral Consult social services Have pt. verbalize Joyce Workman - Educational - increased Fall Risk - normal Health Change - increased Neurological - normal Pain - normal Psychological Needs - normal Sensorium - normal Joyce Workman - Enhanced readiness for learning Ineffective health maintenance Imbalanced nutrition Risk for injury Joyce Workman - Scenario #1 Ask Mrs. Workman Explain in laymen terms Discuss lifestyle choices Discuss lifestyle changes Document teaching Scenario #2 Asses Mrs. Workman's knowledge Ask Mrs. Workman for 24-hour diet Educate Mrs. Workman Provide Mrs. Workman Ask Mrs. Workman to demonstrate Scenario #3 Assess pt's preferred Ensure the pt. Provide an exercise routine Review with Mrs. Workman Use teach back Scenario #4 Assess pt's blood glucose Provide 20 gram carb Provide another Reassess blood glucose Proved additional teaching Scenario #5 Assess Mrs. Workman's understanding Explain to Mrs. Workman Explore new ways Provide information Document education Kate Bradley - Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Neurological - increased Kate Bradley - Acute pain Bleeding, risk for Impaired comfort Impaired mobility Deficient knowledge Fall, risk for Infection, risk for Kate Bradley - Scenario #1 Complete full assessment Secure help Medicate Contact nursing supervisor Complete bed bath Scenario #2 Reassess VS Report discrepancy Notify HCP Contact IV team Document all findings Scenario #3 Explain to surgeon Check on labs Contact charge nurse Meet with daughter Assess pt. Scenario #4 Provide therapeutic Assess last medication Assist the IV team Explain to daughter Contact social services Scenario #5 Witness daughter Call report 88 y/o female Former nursing home Pt. has a foley Have daughter stay Kathy Gestalt - Educational - increased Fall Risk - increased Health Change - increased Pain - normal Psychological Needs - increased Sensorium - normal Kathy Gestalt - Acute Pain Impaired mobility Impaired skin integrity, risk for Anxiety Deficient knowledge Fall, risk for Decisional comfort Disturbed body Kathy Gestalt - Scenario #1 Check pedal cap refill Educate pt. Evaluate understanding Adjust crutches Assist pt. OOB Scenario #2 Wash & glove VS assessment Administer anit-pyretics Verify call light Document results Scenario #3 Inspect cast site Assess toe movement Notify Dr. Document results Scenario #4 Assess pain Elevate extremity Educate pt. Notify lead nurse/Dr Retrieve cast removal tool Scenario #5 Use therapeutic Notify lead nurse/Dr Consult social services Evaluation pt. Document consults Keaton Henderson - Educational - increased Fall Risk - increased Health Change - increased Neurological - normal Pain - normal Psychological Needs - normal Keaton Henderson - Acute pain Bleeding, risk for Impaired comfort Fall risk Keaton Henderson - Scenario #1 Introduce Take vitals Auscultate lungs Inspect pleurovac Mark drainage level Scenario #2 Assess VS Assess insertion site Check pleurovac Administer pain meds Encourage use of IS Scenario #3 Asses for mediastinal shift Administer 100% O2 Auscultate lungs Assess pleurovac Cal rapid response Scenario #4 Explain to pt. Obtain 16 gauge angiocath Set up sterile Obtain & fill Assist with insertion Scenario #5 Assess VS Auscultate lungs Complete chest x-ray Inspect insertion site Ensure chest tube Linda Yu - Educational - increased Fall Risk - increased Health Change - increased Neurological - increased Pain - increased Psychological Needs - increased Linda Yu - Acute pain Impaired mobility Fall risk Risk for infection Linda Yu - Scenario #1 Assess current pain Obtain VS Complete initial assessment Educate pt. Place personal aspirin Scenario #2 Assess for injury Obtain assistance Take VS Complete skin assessment Notify healthcare provider Scenario #3 Administer medication Address pt's skin tear Obtain bedside Prepare pt. Assign a UAP Scenario #4 Assess leg Treat pt. Educate pt. Contact power of attorney Collect pre-op labs Scenario #5 Assess VS & UO Start secondary IV Have a 2nd licensed nurse Take VS Assess pt. & VS Mark Robinson - Educational - increased Fall Risk - increased Health Change - increased Neurological - normal Pain - increased Psychological Needs - normal Mark Robinson - Bleeding, risk for Impaired comfort Deficient knowledge ETOH withdrawal, risk for Mark Robinson - Scenario #1 Educate pt. Draw labs Initiate large bore IV Advise pt. Initiate I&O Scenario #2 Stop the pt. Explain to the wife Reassess pt. Call GI provider Explain to pt. & wife Scenario #3 Identify the client Check the client Document necessary Check VS Recheck VS q 5 min Scenario #4 Repeat H&H Administer ordered meds Explain to the pt. Verify with blood bank Verify soft, low sodium Scenario #5 Stop the platelets Reassess VS & obtain UA Notify HCP Call charge nurse Initiate incident report Nathaniel Gonzalez - Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Neurological - normal Nathaniel Gonzalez - Acute pain Deficient knowledge Fall, risk for Nathaniel Gonzalez - Scenario #1 Tell the pt. that Perform admission Tell the pt. to Explain to the pt. Ensure the bed Scenario #2 Explain to the pt. Reinforce the risk Administer the medication Assess if the contents Remove the lunch tray Scenario #3 Assess pt's LOC Elevate HOB Reapply NC Remove the dinner tray Reassess pt. q 5 min Scenario #4 Restart IV Give NS liter bolus Recheck Tilts Remind pt. Draw a repeat CBC Scenario #5 Assess pt's pain If gastric reflux If cardiac Assess pt's anxiety Verify if discharge Paul Greer - Educational - increased Fall Risk - normal Health Change - increased Pain - normal Psychological Needs - normal Neurological - normal Paul Greer - Impaired comfort Deficient knowledge Sexuality Paul Greer - Scenario #1 Complete initial Check patency Medicate for pain Explain to pt. Inform pt. Scenario #2 Tell the wife Explain to Mr. Greer Teach the pt. Evaluate pt's understanding Continue to observe Scenario #3 Using therapeutic Contact HCP Provide the pt. Provide a diversional When the HCP Scenario #4 Complete head-to-toe Ensure pt. privacy Complete secondary Reinforce to the pt. Notify HCP Scenario #5 Ask the pt. if it is okay Explain that Docetaxel Explain that Radium-223 Ask the pt. to verbalize Assess pt's understanding Roger Clinton - Educational - increased Fall Risk - normal Health Change - increased Pain - normal Psychological Needs - normal Neurological - normal Roger Clinton - Bleeding, risk for Impaired comfort, risk for Impaired mobility, risk for Nausea, risk for Deficient knowledge Infection, risk for Roger Clinton - Scenario#1 Wash hands Explain to Roger Obtain & verify Initiate IV Orient pt. Scenario #2 Orient Roger Take VS Observe & mark Assess pain Fluid status Scenario #3 Head-to-toe Reinforce dressing Notify surgeon Notify charge nurse Instruct pt. Scenario #4 Take VS Keep Mr. Clinton Reinforce dressing Initiate secondary Witness signing Scenario #5 Initiate head-to-toe Check operative Assess for pain Review new orders Encourage Mr. Clinton Ronald Burgandy - Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Sensorium - normal Ronald Burgandy - Acute pain Bleeding Impaired comfort Deficient knowledge Fall, risk for Ronald Burgandy - Scenario #1 Explain to the pt. Ensure there is a full Start and IV Medicate Advise pt. Scenario #2 Explain to Mr. Burgandy Inform Mr. Burgandy Ask Mr. Burgandy Reassure pt. Reassess pt's physical Scenario #3 Assess pt's ABCs Take initial VS Pale pt. on O2 Start IV Set-up Scenario #4 Explain procedure Place pt. on 100% O2 Ensure there is suction Obtain chest tube tray Reassess pt's VS Scenario #5 Instruct Mr. Burgandy Notify charge nurse Call security Transport Mr. Burgandy Complete incident report Ruth Cummings - Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Neurological - normal Ruth Cummings - Acute pain Deficient knowledge Impaired mobility, risk for Nausea Ruth Cummings - Scenario #1 Orient pt. Educate pt. Administer rectal Assess IV Insert NG Scenario #2 Describe to pt. Explain how surgery Practice using IS Reinforce need Evaluate pt. understanding Scenario #3 Ensure signed surgical Take VS Ask pt. to verify Check IV Disconnect NG tube Scenario #4 Receive handoff Assess/inspect Take VS Elevate HOB Give pt. call light Scenario #5 Assis pt. Ensure side rails Notify charge nurse Notify HCP Complete incidence report Trey Johnson - Educational - increased Fall Risk - normal Health Change - increased Pain - increased Psychological Needs - increased Sensorium - normal Trey Johnson - Acute pain Nausea Deficient knowledge Trey Johnson - Scenario #1 VS & head-to-toe Collect stool Initiate IV Initiate I&O Teach pt. Scenario #2 Place pt. Relocate pt. Contact HCP Proved PRN Continue strict I&O Scenario #3 Notify Infection Control Pt. education Initiate medication Continue medicating Discuss coping Scenario #4 Allow pt. Educate pt. Evaluate pt. understanding Notify HCP Document Scenario #5 Educate pt. of protocols Educate pt. of transmission Evaluate potential barriers Educate pt. of need Evaluate pt. understanding Wight Goodman - Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - normal Neurological - normal Wight Goodman - Acute pain Bleeding, risk for Impaired comfort Deficient knowledge Infection, risk for Wight Goodman - Scenario #1 Wash hands & assess Complete neuro Check the blood Pre-op education Ask surgeon Scenario #2 Complete neuro Educate pt. Evaluate pt's understanding Administer IV ABX Sign additional Scenario #3 Complete neuro Educate pt. & family Inform healthcare provider Contact social services Extensive discharge Scenario #4 Repeat neuro Reemphasize to pt. Approach resident Contact nursing supervisor Document Scenario #5 Take VS Restart pt's IV Obtain surgical Assure pt. Remain with pt. Tim Jones - Educational - Increased Fall Risk - Increased Health Change - Increased Neurological - Increased Pain Level - Increased Psychological Needs - Increased Tim Jones - Defensive coping Ineffective health maintenance Risk for post traumatic stress syndrome Risk for injury at home Tim Jones - Scenario #1 Wash hands Reassure pt. Interviewing pt. Complete physical Notify charge nurse Scenario #2 Use therapeutic Seek clarification Reassure Mr. Jones Administer prescribed Offer UAP Scenario #3 Assess Mr. Jones Assist Mr. Jones Provide personal Remind Mr. Jones Obtain a sitter Scenario #4 Notify HCP Administer nebulizer Reassess respiratory Encourage Mr. Jones Document Scenario #5 Talk with Mr. Jones Call Mr. Jones's children Ask Mr. Jones Discuss options Notify the social worker John Wiggins - Educational - increased Fall Risk - increased Health Change - increased Neurological - normal Pain - increased Psychological Needs - normal John Wiggins - Acute pain Deficient knowledge Impaired mobility, risk for Nausea Bleeding, risk for John Wiggins - Scenario #1 Check for cognition Check pupils Check nose and ears Check cranial nerves Assess extremity Scenario #2 Explain to Mr. Wiggins Inform pt. Ask pt. to remain Put side rails up Notify physician Scenario #3 Contact radiology Inform the pt. of the plan Start a saline lock Inform pt. why you are doing Inform the pt. why he will Notify charge RN Scenario #4 Remain with pt. Call for help Note time when Ensure IV access Reassess VS Scenario #5 Assist anesthesia Administer Valium Initiate a second 18g IV Contact family Continue frequent VS Marcella Como - Educational - increased Fall Risk - normal Health Change - increased Pain - increased Psychological Needs - increased Sensorium - normal Marcella Como - Acute pain Readiness for enhanced immunization status Ineffective coping Rape-trauma syndrome Fear Grieving Infection, risk for Disturbed energy field Anxiety Compromised family coping Social isolation Marcella Como - Scenario #1 Use therapeutic Full assessment Provide emotional Document Scenario #2 Use therapeutic Educate pt. Provide supplies Offer to assist Scenario #3 Use therapeutic Ask open-ended Seek clarification Summarize Scenario #4 Restsate or paraphrase Acknowledge Review plan Notify social services Document Scenario #5 Review labs Educate pt. Provide emotional Discuss support Preston Wright - Educational - increased Fall Risk - increased Health Change - increased Neurological - normal Pain - increased Psychological Needs - normal Preston Wright - Acute pain Altered body image Impaired physical mobility Impaired tissue integrity Risk for imbalanced nutrition Risk for infection Risk for injury related to falls Preston Wright - Scenario #1 Assess current pain Assess documented pain Review medication Prepare and administer Reassess pain Scenario #2 Asses Mr. Wright's willingness Eliminate as many Explain rationales Assess understanding Document Scenario #3 Remove old dressing Assess the injury Assess and document Measure wound size Re-apply new sterile dressing Scenario #4 Don clean gloves Remove clean gloves Clean wound Place sterile moistened Secure dressing Scenario #5 Explain S/Sx Encourage Mr. Wright Assess understanding Alert Mr. Wright's case manager Call Report John Duncan - Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - normal Sensorium - normal John Duncan - Deficient fluid volume Electrolyte imbalance, risk for Fatigue Fall, risk for Noncompliance John Duncan - Scenario #1 Assess I&O Construct dietary consult Acquire daily weight Evaluate outcome Scenario #2 Full assessment Check I&O Teach pt. about safety Document Scenario #3 Wash/glove hands Provide emesis basin VS assessment Administer antiemetic Evaluate medication Scenario #4 VS assessment Assessment of bowel Administer protocol Document results Include pt. condition Scenario #5 Inform & educate spouse Evaluate/modify Assess food Document Karen Cole - Educational - increased Fall Risk - normal Health Change - increased Pain - normal Psychological Needs - normal Sensorium - normal Karen Cole - Impaired coping Risk for impaired comfort Infection risk Risk for injury Karen Cole - Scenario #1 Apply O2 Connect pt. Complete full assessment Obtain IV access Orient pt. & husband Scenario #2 Give IV morphine Reassess VS Notify Cath lab Obtain informed consent Transport pt. Scenario #3 Take VS Post-op assessment Ensure pressure dressing Instruct pt. Assess pain Scenario #4 Explain the necessary Perform hand hygiene Remove infiltrated IV Don new gloves Insert new IV Scenario #5 Asses pt. & family Provide pt. post MI Pt. & family should Schedule cardiac Document Tom Richardson - Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - normal Sensorium - normal Tom Richardson - Acute pain Impaired mobility, risk for Impaired urinary elimination Fall, risk for Tom Richardson - Scenario #1 Wash & glove Vital assessment Administer Reassess pt. Document Scenario #2 Vital assessment Notify Dr. Administer new Reassess pt. Scenario #3 Use therapeutic Obtain urinary Assist pt. Remain w/ pt. Document Scenario #4 Use therapeutic Educate pt. Evaluate understanding Contact dietary Document Scenario #5 D/C instruction Evaluate understanding Escort pt. Document Notify housekeeping Mary Barkley - Educational - increased Fall Risk - normal Health Change - increased Neurological - normal Pain - increased Psychological Needs - increased Mary Barkley - Acute pain Deficient knowledge Grieving impaired comfort Infection Mary Barkley - Scenario #1 Have pt. Wash hands Use therapeutic Guide her back Set her up Scenario #2 InitiateO2 Scenario #3 Contact RT Obtaintelemetry Ask PCT Don PPE Assist RT Scenario #4 Call rapid response Continue to assist Give SBAR Call for crash cart Ensure documentation Scenario #5 Encourage the HCP Offer to contact Contact assisted living Notify HCP Assist w/ intubation Richard Dominec - Educational - increased Fall Risk - normal Health Change - increased LOC - normal Pain - increased Safety - increased Psychological Needs - normal Sensorium - normal Richard Dominec - Acute pain Knowledge deficit Nutrition Risk for infection Skin integrity at risk Fera/anxiety Richard Dominec - Scenario #1 Perform full assessment Provide comfort Check surgical consent Inform his partner Scenario #2 Educate about recovery Discuss his understanding Offer assistance Determine from medical Scenario #3 You discuss this cough Notify Dr. of change Explain to Mr. Dominec Explain that he will Notify charge nurse Scenario #4 Inform pt. about Obtain and provide Encourage Mr. Dominec Document and provide Scenario #5 This information Remind staff Leave the break room Report this activity Ramona Stukes - Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - normal Sensorium - normal Ramona Stukes - Bleeding, risk for Deficient fluid volume, risk for Impaired mobility Fall, risk for Infection, risk for Ramona Stukes - Scenario #1 Wash & glove Full assessment Allow expression Educate pt. Evaluate understanding Scenario #2 Wash & glove Full assessment Check NG tube Administer IV antiemetic Scenario #3 Full assessment Educate pt. Evaluate understanding Notify lead RN Consult wound care Scenario #4 Discuss w/ pt. Notify lead RN Contact social services Update pt. Scenario #5 Follow HIPAA Explain HIPAA Offer resource Contact wound care Document Kenny Barrett - Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - normal Sensorium - increased Kenny Barrett - Acute pain Deficient knowledge Fall risk Kenny Barrett - Scenario #1 Perform hand hygiene Reassess BP & P Evaluate pt's understanding Administer Document Scenario #2 Retake VS Instruct pt. Perform comfort Request CNA Notify the HCP Scenario #3 Pt. Kenny Barrett Pt. was admitted Current VS Request possible change Scenario #4 Take VS not Maintain strice 500 mL NS Hold next dose Contact HCP Scenario #5 Assess stress level Communicate Discuss willingness Educate pt. Contact HCP Lithia Monson - Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Sensorium - increased Lithia Monson - Bleeding, risk for Imbalanced nutrition Self-care deficit Acute confusion Fall, risk for Failure to thrive Lithia Monson - Scenario #1 Perform neuro Reorient pt. Assess for fall Offer nutrition Scenario #2 Explain reason VS assessments Apply restraint Perform circulatory Request sitter Scenario #3 Employ therapeutic Release restraints Reapply restraints Perform circulatory Document Scenario #4 Use therapeutic Attempt to orient Perform circulatory Offer nutrition Document Scenario #5 Check monitor Apply NC O2 VS reassessment Notify lead RN Remain w/ pt. Charlie Raymond - Educational - increased Fall - increased Health Change - increased Neurological - normal Pain - normal Psychological Needs - normal Charlie Raymond - - Death anxiety - Impaired gas exchange - Ineffective breathing pattern Charlie Raymond - Scenario #1 Don appropriate PPE Change to simple Perform focused Notify respiratory therapy Notify family Scenario #2 Reorient pt. Obtain a sitter Restart IV Begin strict Obtain an order Scenario #3 Use therapeutic Position the pt. Create sterile Baby Strickland R03 Baby Strickland, 1-hour-old newborn female, 37-week gestational age born via C-section, weight 9.9 lbs. Mom has history of diabetes, not well controlled. Estelle Hatcher R301 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, NGtube 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 Hayden Clark R302 Hayden Clark, 6-year-old male, weighing 44 lbs., comes to school looking disheveled, and not wearing a coat with the outside temperature in the low 40’s Preston Wright R305 Preston Wright, 73-year-old male patient of Dr. Greene, status post CVA 4 weeks ago. He has been readmitted for a red spot on his sacrum of 1 cm and a 2 cm blister on his right heel. IV fluids of D5 1/2 NS are infusing at 100 mL/hour to his right forearm. Mr. Wright is pleasant and cooperative but needs to be reminded to avoid pressure on his heel and sacrum. Post CVA, he has developed some aphasia and is having difficulty with verbal communication. He has orders for dressing changes q daily and pain medications before the dressing change Jack Hammond R305 SR Jack Hammond, 10 -year old boy who was admitted last night for cystic fibrosis exacerbation and possible pneumonia. He has an IV of D5 NS infusing to his right arm at 75 mL/hour. Oxygen per nasal cannula is in place at 3 L/min, chest x-ray results and sputum culture are pending. He is alert and oriented, both parents are currently at the bedside. He does complain of intercostal pain, especially with coughing. Current oxygen saturation is 94% Calvin Umbyuma R302SR Calvin Umbyuma Mr. Umbyuma is a 42 y/o male who has been admitted for complaints of shortness of breath with pleuritic chest pain. He was diagnosed with HIV positive antibodies over a year ago. He has recently been traveling back to his home country of Kenya to visit his sick mother. He received traditional medical treatment at his village. His temp is 100.9 F, 38.3 C, R 22, P92, BP 152/89 PaO2 91%. Inflammatory markers – Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) are elevated at 78.9 mm/h and 67.2 mg/L. He has been placed in a room at the end of the hall. Carlos Mancia R301SR 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 Cameron Daniels R 304 SR Cameron Daniels just turned 18 y/o. She is being admitted from the ER with a diagnosis of pelvic inflammatory disease (PID). She has heavy vaginal discharge with an unpleasant odor. She is complaining of abdominal pain and looks pale. She was seen by OBGYN in the ER and a culture was sent to the lab for Chlamydia and/or Neisseria Gonorrhea. She was a very difficult IV start and has a 23g saline lock (SL) in her right hand. They have ordered a liter bolus of LR, but it is running very slowly and the IV is positional. VS BP 96/58, P 116, R 18, T 101.2 PaO2 92%. Dotty Hamilton R304SR Dotty Hamilton 52 y/o female who has been admitted for bariatric surgery. She has arrived at 0600 and is scheduled for a laparoscopic Roux-en-Y gastric bypass (RYGB). She is super morbidly obese with a BMI of 52, Ht, 5'3", Wt, 293lbs. She has well-controlled hypertension with Losartan (Cozaar) 50 mg q daily. She also takes Metformin to control her Type 2 Diabetes. She has sleep apnea, and she brought her CPAP machine. She is very excited about the surgery but is also apprehensive. A friend told her that the complication rate for this surgery is very high. She believes this surgery is her only hope, as she says she has tried everything else to lose weight. Her husband is with her and seems to be very supportive. Body Mass Index (BMI) = kg/m2, where kg is a person's weight in kilograms and m2 is their height in meters squared. A BMI of 25.0 or more is overweight, while the healthy range is 18.5 to 24.9. Example: Weight = 133.18 kg, Height = 160.02 cm (1.60 m) Calculation: 133.18 ÷ (1.60)2 = 52 Arthur Silverstein R SR Arthur Silverstein, Arthur Silverstein, a 68-year-old homeless Vietnam veteran recently hospitalized for PTSD resulting from the abuse suffered during imprisonment by Viet Cong. Arthur lives in a homeless shelter. He has experienced intermittent homelessness and alcohol addiction since his wife died 18 years ago. Arthur experiences flashbacks and nightmares. He is hyper-vigilant and becomes anxious in crowded spaces or in large groups of people. Medications: NKDA. Paroxetine (Paxil) 30 mg daily for management of depression, hypervigilance and PTSD symptoms and zolpidem (Ambien) for sleep as needed. Social history: Arthur lives in a homeless shelter. Arthur openly struggles with the day room and the men’s living quarters due to the number of people and limited personal space. Because of Arthur’s alcohol addiction he has been denied access to the shelter if he was intoxicated forcing him to sleep outdoors, regardless of the weather. Arthur has three children that he has not seen since shortly after his wife died due to his mental health and alcohol abuse. Linda Pittmon Room SR304 Linda Pittmon isa 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.". What screenings and assessments should you antipate needing? Paul Windsor SR Paul Windsor, 4-year-old male admitted yesterday from the clinic with a diagnosis of Nephrotic Syndrome. Vital signs: Temperature 99.0, HR 88, BP 104/76, RR 22, PaO2 95%. He presented yesterday with his parents reporting a gradual increase in pain and “swelling” around his eyes and ankles, and now his stomach is getting “bigger". Paul has little to no appetite. Current weight is 56 pounds compared to a usual weight of 43 pounds. Urinalysis: Thick, frothy appearance. Specific gravity: 1.025. Protein 3+. Blood 2+. Other labs: Triglycerides 180 mg/dl. Cholesterol 190 mg/dl. Group B strep culture negative in office. Roger McClusky RSR Roger McClusky, 70-year-old male recently diagnosed with Alzheimer’s Disease dementia following evaluation of forgetfulness, difficulty processing new information, and increased confusion. With his declining memory and hearing impairment Roger’s daughter, Lisa, is concerned about his ability to care for himself and is interested in care options to assist him in staying in his home. Medications: NKDA, memantine (Namenda) one tablet daily. Social history: Roger lives alone in a two-bedroom home in a rural community. Roger came to the community as a migrant worker 40 years ago and worked as farm help for a local farmer providing manual labor in the fields. Roger is active in his church and attends with the men’s Bible study weekly. His daughter lives nearby and visits Roger multiple times per week. Community Assessment: Roger lives in a small rural community with a small downtown. On the Main Street there is a grocery store, a family-owned pharmacy and milk shake shop, gas station, diner, second-hand store, and an outreach family practice clinic. There are two churches, one on the north side and one on the west end of town. The houses are spaced “a country mile,” separated by farmland and fields. Most of the side roads are gravel. There are no public transportation options. Ann Rails SR 305 Ms. Rails has bruises to her right forearm and face. She complains of back pain 6/10 pain scale. She was medicated with hydrocodone 5 mg PO two hours ago. Her vital signs are BP: 110/60, P: 74, R: 20, PaO2: 98%, T: 98.6 F, 37 C. Ms. Rails has told you that she is concerned about returning home and is afraid her boyfriend will return. She also expressed concern about finding a new job Hildegard Lowe R303 SR Hildegard Lowe, 68 y/o female, newly admitted after a rough night in the ER after coughing for the last 2 months. Patient is alert and cooperative, visually limited and declining. She is on Oxygen at 2L. She has an IV 0.9 normal saline, 125 an hour. Chest x-ray upon admission showed right middle lobe pneumonia. Vital signs are BP: 128/86, P: 105, R: 32, T: 99.8 F, 37.7 C, SaO2: 93%. Plan of care is antibiotic therapy, incentive spirometry, O2 supplementation, and pending labs and blood cultures from the ER. Patient is receiving Rocephin and received Zithromax in the ER. Patient does have a history of Granulomatosis with Polyangiitis but has been stable for 5 years w/o treatment. She is widowed and came to us from the retirement community. She has one daughter who is on her way from out of state; she will be arriving sometime today. Patient states she is allergic to mangos. Mary Jane RSR Mary Jane , Mary Jane is a 21-year-old female who was recently discharged from the behavioral health unit. Mary Jane was engaging in cutting, sleeping excessively, was unable to complete tasks, and had feelings of worthlessness. While in the behavioral health unit, Mary Jane exhibited signs of severe anxiety. Mary Jane was diagnosed with major depressive disorder and prescribed Tofranil. Discharge plans included continuation of imipramine and outpatient therapy. Medications: imipramine (Tofranil) 100 mg daily. NKDA. Surgical history: Appendectomy age 10 Social history: Mary Jane lives at home with her parents. She is currently unemployed, and looking for meaningful employment. She dropped out of college because she was unable to concentrate and was experiencing overwhelming anxiety and depression symptoms. Jody Rush 306 SR 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 Provider 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. She denies ever losing consciousness. Patients affected extremity has normal pulses, and the capillary refill is less than 3 seconds. Maria Sanchez Room Maria Sanchez , 20-year-old female, G1 T1 P0 A0 L1. Maria had an uncomplicated pregnancy and normal spontaneous vaginal delivery at 39 weeks. She delivered a 3500 Gram male infant, Juan. Maria is at the clinic for her 6-week post-partum visit. Maria shares with the nurse she is feeling anxious and overwhelmed. Maria states she attempted to breastfeed but quit because “Juan ate all of the time and cried most of the day.” Maria’s grandmother requested the Curanderos visit the house to guide Le Cuarentena. Maria explains Le Cuarentena is a period of 40 days after a baby is born during which time the mother should do nothing but take care of herself and the baby. Maria said, “grandmother told me Juan has colic because I did not eat the right hot foods after Juan was born and that the breastfeeding trouble was too much during the Le Cuarentena.” Maria tearfully expresses, “I failed as a mother.” Medications: NKDA Prenatal vitamins and herbs from the Curanderos Social history: Maria lives in a multigenerational home with her husband, Raul; 6-week infant, Juan; her mother and grandmother. Maria and her family primarily speak Spanish; today’s visit includes an agency interpreter. Michael Houston R Michael Houston, 4-month old admitted with runny nose, decreased appetite, dehydration, and cough. Respiratory Syncytial Virus (RSV)/Bronchiolitis is suspected. He was born at 36 weeks and spent time in the NICU for respiratory issues and patent ductus venosis that resolved with oxygen treatment and time. A rRT-PCR on nasal secretions is pending, as is a chest xray. Vital signs are: Temp. 99.3 F, RR 54, HR170 with audible wheezes. Mark Quinn R303 Mark Quinn, 9-year-old male comes to the school nurse with complaints of abdominal pain and nausea. Vital signs: Temperature 98.2, HR 87, BP 104/ 67, RR 22, PaO2 97%. The nursing assessment reveals diffuse lower abdominal pain, tenderness, and normoactive bowel sounds. After consultation with the child and the parents, the child is sent home with a possible viral intestinal infection. Suzanne Williams R305 Suzanne Williams, 5-year-old female, weight 35.2 lbs., recently diagnosed with leukemia. CBC results: neutrophil count 1.7, white blood count 30,000. She is reporting gradual arm and leg pain at a 6/10 over the last 4 weeks. Parents attributed pain to “growing pains”. Patient experiencing n/v/d and loss of appetite. Vital Signs Temperature 100.8, HR 115, BP 100/65, RR 23, PaO2 95%. The patient is beginning a second round of chemotherapy. John Davis R301 John Davis is a 54 y/o male admitted for surgical resection and biopsy of multiple lesions on his back and shoulders. The patient is fair skinned with multiple moles on his shoulders and anterior and posterior torso. The patient is high risk for basal cell carcinoma and has had mole - mapping. Mr. Davis is very thin and reports an 8 lbs. weight loss over the last four months. He owns a landscape business, works outside, he also enjoys being out on his boat. He had a basil cell carcinoma removed from his forehead four years ago (Mohs micrographic surgery) which has left a large scar. Mr. Davis is concerned about potential scars from these lesions. He denies any other health issues. The patient does not smoke, but drinks 2 beers after work daily and more on the weekends. VS BP 150/89, P 62, R 14, T 98.2. Jim Goodman Sr Jim Goodman, A home health nurse is scheduled to see a new client, Jim Goodman, for weekly home health visits. Jim is a 77-year-old male with end-stage steroid-dependent COPD. He has had five hospitalizations over the past six months for COPD exacerbations. He is 69 inches tall and weighs 155 pounds. His comorbidities include hypertension, asthma, anxiety, and tobacco abuse. There is concern about the client’s adherence to the medication regime. The client is occasionally disoriented to place and time. Medications: NKDA. Oxygen nasal cannula 3 liters, Prednisone 5 mg daily Ipratropium Bromide/Albuterol Sulfate 3 mg/0.5 ml/cc solution four times daily via nebulizer Fluticasone one puff every 12 hours Amitriptyline 2.5 mg daily oral Metoprolol 200 mg daily oral Albuterol inhaler 2 puffs as needed. Surgical history: Jim’s surgical history is positive for a ruptured abdominal aortic aneurysm fifteen years ago and a subsequent abdominal hernia repair. Social history: Jim lives in a 55 and older low-income apartment building with his wife in a small rural community. He smokes 15 cigarettes per day, he does not drink alcohol, and he walks around the block four times per week. Community Assessment: small rural community with a main street with retail shops, restaurants, bank, a pharmacy, grocery store and a department store. The houses and buildings are well kept. The sidewalks near Jim’s apartment building are in moderate disrepair with some uneven surfaces and cracks. There are no open green spaces in the community or evidence of public transportation. Roger Clinton SR Roger Clinton, 57-year-old male construction worker arrives at 0600 to be prepared for a partial thyroidectomy to determine if he has cancer. His past symptoms for three months have been that he noticed a slight hoarseness in speaking, a slight dry cough not related to a cold, and upon examination had a “pea-size" lump on the center of his neck. His Endocrinologist had a radioiodine scan performed that showed a suspicious area. The plan is to obtain a biopsy from several areas of the thyroid gland, and hopefully to leave as much as possible in place. Roger knows that it will take three days after surgery to determine if he has cancer but does not understand the implications resulting from a thyroidectomy. (Lifetime thyroid replacement medication.) Linda Yu R302 Linda Yu, was admitted to your unit after surgery on her left hip due to a fall. She is 2 days post-op. She is 85 years old and has a history of osteoarthritis and cataracts. PT has been getting the patient up with a walker and she is able to take a few steps. She is aware of herself and the situation, but no time or day. She is also anxious as a result of recent surgery. Her family lives out of state, but the daughter was here for the surgery, she left yesterday. The plan is to discharge Ms. Yu back to her assisted living facility. Her daily medications at home include: Prednisone 5 mg, Furosemide 20 mg, and ASA 81 mg daily. The surgeon added oxycodone 5mg q 4-6 hours prn pain. NKDA. Suzanne Olsen SR Suzanne Olsen, 24-year-old female who comes to the community clinic with complaints of increased vaginal discharge, pain with intercourse, lower abdominal pain, and urinary frequency. Suzanne reports her symptoms started over a week ago. Suzanne is accompanied to the clinic by her boyfriend. Suzanne is 5 feet 6 inches tall, 117 pounds. BP 132/76 mmHg, T 100.2 F. (37.9 C.), P 88 beats/minutes, RR 18 breaths/minutes. Medical history: Suzanne’s medical history is significant for five elective first trimester pregnancy terminations and two full term spontaneous vaginal deliveries. Suzanne’s boyfriend states she gave the two children up for adoption. Medications: NKA. Surgical history: T & A age 5 Social history: Suzanne is new to the area and has not established a primary care provider. When asked what she does for employment, her boyfriend states because she is new to the area, she is unemployed and does not currently have insurance. He states that they are living in his apartment but are looking for another place to live. Sarah Kathryn Horton R305 Sarah Kathryn Horton, 25-year-old graduate student was brought to the emergency room via ambulance after being shot on the local college campus. Sarah was admitted to Med-Surg at 2am. She has two through and through gun-shot wounds. One to her right thigh and one to her right shoulder. She has a 20- gauge peripheral IV to left forearm with 75 mL/hr. of 0.9% saline infusing. Vital signs are stable at this time, alert and oriented x3, reports pain 6/10. She remains tearful and has been told that her best friend died on the scene. Virginia Smith 303 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%. Ramona Stukes RSR Ramona Stukes, Ramona Stukes is a 69-year-old female who had a failed cholecystectomy and subsequent ileostomy. Ramona was discharged postoperatively to home six weeks ago. Ramona’s ostomy appliance has been leaking. She is frustrated and overwhelmed with the new appliance and the fact it is not working properly. Ramona’s neighbor, Shirley, has been assisting in her care since she has been home because Ramona’s husband is unwilling to assist with her ostomy care. She is 64 inches tall and weighs 226 pounds. Medications: NKDA. Oxycodone with acetaminophen (Percocet) 1-2 tablets every four hours as needed for postoperative pain, gabapentin (Neurontin) 300 mg by mouth three times daily for chronic nerve pain and ketorolac (Toradol) every 6 hours as needed for breakthrough pain. Medical history: Ramona was diagnosed with and has been treated for chronic nerve pain. Ramona reports “I have had so much pain since the surgery. I take all the medicine I can but it still doesn’t help.” Surgical history: positive for a ruptured appendectomy at age 18 and her recent history of failed cholecystectomy and subsequent ileostomy. Social history: Ramona lives in a single-family home with her husband. Both Ramona and her husband are retired. Community Assessment: Ramona and her husband live in a single- family home in a rural farming community. The town is 4 miles south of their home and consists of the local 745 VFW, a church, and gas station with a convenience store, and a small café. The next nearest town, Twin Valley, is 12 miles from their home has a population of 37,000. Twin Valley offers a large discount department store with a pharmacy, two large service grocery stores and multiple restaurants, places of worship, banks and on and off liquor sales, and specialty shops. Twin Valley is home to a critical access hospital and an outreach specialty clinic supported from the major city 37 miles south. Ann Rails R Ann Rails, The nurse provides community health consultation to a domestic violence shelter. Ann Rails is a 38 years old female recently hospitalized for evaluation of back pain and leg pain, numbness in her legs bilaterally, left leg weakness and an unsteady gait. Ann was discharged to a women’s domestic violence shelter after she disclosed to her nurse that she was afraid to go home to an abusive husband. Ann’s discharge plan, in addition to safety, protection, and supportive services from the women domestic violence shelter included pain management and restoration of a normal gait. Most recent vital signs: BP 124/82 mmHg, Temp 98.2 F (36.8 C), P 84 beats per minute, RR 22 breaths per minute, SaO2 96%. Medical history: Other than Ann’s recent hospitalization, her past medical history is otherwise non-significant. Medications: No known allergies (NKA). Hydrocodone 5 mg po as needed for pain; Acetaminophen 325 mg one – two tabs every four hours po as needed for pain, Gabapentin 300 mg three times daily po for nerve pain. Surgical history: Negative. Social history: Prior to her hospitalization, Ann lived with her husband and their 2 dogs. Ann did not work outside of the home Charlie Raymond R301 Charlie Raymond, 65-year-old male who was admitted to a negative pressure room on Med-Surg for COVID precautions. He has a history of COPD, hypertension, diabetes type II, and a recent myocardial infarction. He is a retired postal worker who lives at home with his wife. He is on Claforan (cefotaxime) 2 g IV BID hr and sliding scale insulin. Initially this cardiologist was concerned about congestive heart failure and Mr. Raymond is receiving Furosemide (Lasix) 20 mg IV twice a day for pulmonary edema. Vital Signs: BP is 145/78, Pulse 89 Respirations 24 and slightly labored, Temperature 100.2 SaO2 94% on 2L nasal cannula. The patient/family is fearing the worst due to COVID-19 Pandemic. Antel Musaka R Antel Musaka, 13-year-old entering the 6th grade in middle school. Antel experienced cerebral anoxia during a prolonged labor and delivery which resulted in cerebral palsy, quadriplegia, and developmental delay. Although his physical development is delayed, Antel uses a communication board and is on grade level with his intellectual development. Six months ago, Antel underwent a posterior spinal fusion to treat scoliosis and ensure proper alignment in his adapted wheelchair. Antel attends school and participates inacademic, physical, and occupational therapies. Antel has been treated for many years for gastroesophageal reflux. He has a percutaneous endoscopic gastrostomy (PEG) tube for feedings and medications, but he can eat by mouth. Antel has a history of aspiration pneumonia and drools a lot. Antel has a history of seizure activity and receives carbamezepine via the PEG tube. Antel has multiple pressure areas on his body due to his random spastic movements, functional immobility, and lack of voluntary coordination. Antel lives at home with his parents. His mother is his sole careprovider, although she tried to encourage Antel’s father to assist in care. Antel’s father tells the community health nurse “I just don’t like to provide personal care for my son, in my culture a father should not care for his teen son that way.” Antel’s mother appears fatigued and tearful. The community health nurse explores some tasks that Antel’s father may assist with, including PEG tube feedings and medications. Antel’s family is not aware of nor do they use community resources. Although Antel’s family has adequate financial resources, Antel’s care has depleted the family’s available insurance and they have high deductibles and co-payments. Mary Barkley R306 Mary Barkley, 74y/o female has been admitted to your floor with a respiratory infection and she has tested positive for COVID-19. She resides in an assisted living facility which has seen four deaths related to COVID-19. 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 of 99.8 F, SpO2 91%, 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. Jenny Smith R Jenny Smith, 23-year-old G2P1 who presents at the clinic after having a dilatation and curettage (D and C) following a spontaneous abortion at 10 weeks gestation six weeks ago. During her hospital discharge instructions, Jenny was advised to schedule a 1-2 week follow-up appointment with her provider to ensure a safe physical recovery and to discuss either birth control or to plan her next pregnancy if she desires to try again. Jenny cancelled her 2-week post-operative appointment because she “felt fine.” She presents today with complaints of lower abdominal pain, generalized malaise, swollen glands, and body aches. Jenny is also requesting a long-term contraceptive option. Jenny admits her last pregnancy was not planned and “I do not want to go through that again and I don’t want my family to go through it again”. She is particularly concerned for her 4-year-old son who keeps asking “Where is the baby?” Jenny admits this has been very hard emotionally for her and her mom. Her significant other is generally supportive, he also grieves the loss of the pregnancy. BP 130/70 mmHg, T 98.8 F (37.1 C), P 90 beats/minute, RR 18 breaths/minute Medications: Prenatal vitamins. Allergies: Sulfa drugs Social history: Jenny lives in an apartment with her 4-year old son. Jenny is a second-grade teacher. Jenny’s significant works in building construction and he was the father of the previous pregnancy. He splits his time with Jenny and with children from a previous relationship. Jenny and her mother are very close, and she talks with her mother every day Kathy Gestalt R303 Kathy Gestalt, 33yr-old, Dx- second-day post-op open right Tibia/Fibula fracture, plaster cast in place on the 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 reluctant regarding walking on leg. Diet as tolerated, up ad-lib after gait training. Crutches at bedside adjusted for height. Dr. Anderson Gina Smith Room Gina Smith, 56-year-old female who has experienced a number of significant life changes over the past year as a result of her alcohol and IV drug addiction. Medical history: Six months ago, Gina was hospitalized for alcohol addiction. At that time, she was experiencing gastric pain, elevated liver enzymes, and was prescribed disulfiram (Antabuse). Gina is taking fluoxetine for depression and anxiety. Medications: NKDA. Fluoxetine (Prozac), one tablet by mouth daily. Social history: Gina lost her job as a graphic artist because she came to work intoxicated on two occasions. Due to her unemployment and addictions, she did not pay her rent and was evicted from her apartment. Gina has been forced to spend nights either in the shelter or “couch surfing.” Due to the stress of being unemployed and homeless, Gina began to drink alcohol again because it “numbs the pain.” In Gina’s struggle to find work to pay for her alcohol addiction, she resorted to delivering drugs for drug dealers and began using IV drugs. Kenny Barrett Room Kenny Barrett, Kenny Barrett is a 64-year-old male recently hospitalized for management of undiagnosed hypertension. It was determined Kenny’s hypertension and lower extremity pain was related to vasculitis. Kenny was diagnosed with Buerger’s Disease. Medications: Atenolol 50 mg daily. Tylenol 325 mg prn pain. NKDA Surgical history: Kenny’s surgical history is positive for a cholecystectomy and inguinal hernia repair. Social history: Kenny is widowed. He lives alone in a two-bedroom home in a rural community. Kenny recently retired and does not work outside of the home. He admits to struggling financially and being dependent on his savings until he can receive social security. He smokes one pack per day. The pain in his lower extremities prohibits his engagement in exercise. Community Assessment: Kenny lives in a rural community with limited resources. Kenny’s home is on a dirt road, the nearest neighbor is “one country mile” away. Kenny lives seven miles from the farm co-op where he can purchase fresh vegetables and milk. To purchase items not available from the co-op, Kenny must go to “town” nearly thirty miles from his home. There is a family physician in town, however, the nearest hospital and specialty clinics are 80 miles. Kenny receives his prescriptions via mail. Kenny travels via his car, which is unreliable. Hannah Johnson R302 Hannah Johnson, 10-year-old female presented to the ED 45 minutes ago with dehydration, dysuria, and significant weight loss of 18 pounds over the last 2 months. Both parents are with the child, the father is insisting that he be notified of all interventions before they are initiated.  Initial assessment reveals: Skin dry and warm to touch, B/P 90/58, T 99.2, HR 110, RR 30. Child appears thin. Breathing is fast and deep. Noted fruity odor to breath. Initial labs: CBC WNL, K+ 2.89, BG 459, Urinalysis: Positive for ketones, glucose, and bacteria. Orders: IV 0.9% normal Saline at 150 ml/hour, Add 20 mEq K+ after first liter, Ampicillin 250 mg PO q 6 hours, finger stick blood glucose (FSBG) q 1 hour. [Show More]

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