Swift River Med-Surg

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 neurosurgery. The surgeon also orders Neuro checks q2 hours, his Glasgow Coma Score is 15. Scenario 3 Mr. Goodman is first day post-op from his suborbital rim fracture repair, and his orbital edema has been greatly reduced. His CSF with rhinorrhea has subsided. The neurosurgeon has decided to continue to observe his recovery, instead of surgical intervention to repair the orbital roof fracture. The patients VS are stable, and he is afebrile. Patient does not have medical insurance, so he is wanting to leave today. The patient is emotionally distraught, and angry as face appears to have drooping of his eyelid and his visual acuities have not improved. While the swelling has decreased there is still periorbital edema (Ptosis). Scenario 4 The resident has been rounding on Mr. Goodman and is preparing his discharge. Mr. Goodman is still very upset about his appearance. He is also complaining of nasal congestion and insists on trying to blow his nose. The nurse informs the resident that his visual acuities are worse, patient's eyelid is drooping, and his left-eye (OS) pain is increasing . The resident tells the nurse that is a common complication with this type of injury, and they will see him in the clinic for a follow-up. Scenario 5 The attending maxillofacial surgeon comes to see the patient before his discharge at the nurse's insistence. He agrees that the visual acuity is a concern and consults an ophthalmologist. It is discovered that Mr. Goodman has increased intraocular pressure, and it may be a result of suborbital edema which will require STAT surgical decompression to preserve his sight. Mr. Goodman is irate, starts yelling at the nurse, and accidentally pulls out his IV. He believes they have caused him permanent disfigurement and now blindness. The nurse must restart his IV and obtain another surgical consent.

Scenario 1 -Wash hands and assess -Complete Neurological assessment -Check the blood from his nose for CSF (Halo test) -Pre-op education -Ask Surgeon to discuss with patient the potential facial scarring Scenario 2 -Complete Neurological assessment -Educate patient of plan of care -Evaluate patients understanding of care -Administer IV antibiotics -Sign additional surgical consent Scenario 3 -Complete Neurological Assessment -Educate patient and family of necessity for q2 hour neuro checks and visual acuities -Inform Healthcare Provider that patient is medically indigent, and wanting to go home today -Contact social services to discuss options for payment -Extensive discharge planning and education Scenario 4 -Repeat Neurological assessment and contrast your latest findings -Reemphasize to patient that he cannot blow his nose -Approach Resident again, and explain that you feel his condition is worsening -Contact Nursing Supervisor of disagreement of patients readiness for discharge -Document Scenario 5 -Take vital signs and postion patient 30 degrees upright -Restart patients IV -Obtain surgical consent -Assure patient that surgery is necessary to preserve his sight, and that this should not be permanent -Remain with patient

Jody Rush 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 Scenario 3 Jody is more awake, but has become anxious. Her mother is very concerned and insist that they run more tests. The surgeon is called, and he orders Respiratory Therapists to give a nebulizer, as he thinks it is probably her asthma. The treatment does not relieve her shortness of breath, but her lungs are clear bilaterally. The surgeon orders a D-dimer blood test, a computerized tomography pulmonary angiography (CTPA), and a ventilation-perfusion scan, a V/Q scan. Vital signs are BP: 130/72, P: 92, R: 28, T: 99.1 F, 37.3 C, PaO2: 94 Scenario 4 As she is preparing to go into the CT scanner, Jody becomes very short of breath and panicked. She tells the nurse she can't breathe, and becomes inconsolable. Her PaO2: 88, R 30, BP 140/80, P 128. The nurse calls the Rapid Response team (RRT) to radiology stat, and tells the radiology tech to get the interventional radiologist. Scenario 5 Patient goes into electrical mechanical disassociation (EMD) with no palpable pulses. CPR is initiated, and the patient is intubated. The interventional Radiologist attempts to place a Femoral guided catheter to provide thrombolysis of the pulmonary embolism, but is unsuccessful. He insists that CPR continues for 60-90 minutes while they attempt to set-up an Extracorporeal Membrane Oxygenation (ECMO).

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

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 8/10 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 lymph node biopsies have confirmed that the cancer has metastasized, and he will need further treatment. The surgeon has suggested Androgen-deprivation therapy (ADT) with surgical castration (orchiectomy). The patient tells the nurse that yesterday he was, "concerned about having an erection, and now they want to cut off my testicels". He tells the nurse he has called his wife and wants to be discharged now. Scenario 4 The emergency bathroom light goes off and the nurse finds Mr. Greer on the floor in the bathroom. The patient got dizzy when he stood up from the commode. Mr. Greer is on the floor still but is awake and oriented and is complaining of back pain below his right scapula. Primary: Check LOC, Orientation, Breathing, Circulation, Brief Neuro assessment to include spinal pain or deformities, Obvious injuries. Secondary: Assess vital signs, auscultate heart, lungs, and bowl sounds. Auscultate peripheral pulses and ROM. Full head to toe neuro assessment. Scenario 5 Mr. Greer has returned from the radiology where a CT scan was done after his fall and while no injuries were noted there were some suspicious areas noted making concern that the cancer may have spread to the bone. Because of the fall the provider has recommended that he stay in the hospital another night. The oncologist is recommending Docetaxel as opposed to an orchiectomy. They would also like to start Radium-223. The oncologist is insistent that the treatment begin immediately. The patient asks the nurse to explain about these medications and why they are in such a hurry. His children are visiting, and they are very supportive.

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 front of his children. -Explain that Docetaxel is a hormone therapy that suppresses the testosterone that your testicles produce producing similar results as surgical intervention. -Explain that Radium-223 mimics calcium and is absorbed during new bone growth. This will treat any cancer that may have metastasized to the bone. -Ask the patient to verbalize understanding of teaching and reassure them that yourself or any member of their care team will be available to answer questions. -Assess patient's understanding of the teaching and discuss home support

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, SaO2 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.

Physiological- Acute pain: True Bleeding Risk for: False Safety- Deficient knowledge: True Fall, risk for: True Infection, risk for: False

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

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

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 consciousness. Patients affected extremity has normal pulses, and the capillary refill is less than 3 seconds.

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

Robert Sturgess Scenario 1 Mr. Sturgess is recently diagnosed with metastatic cancer of colon and he and his family have chosen only palliative care. Upon entering room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." Scenario 2 It is determined that Mr. Sturgess could achieve better pain control with a PCA pump. Scenario 3 Mr. Sturgess does not have a living will or durable power of care completed. Scenario 4 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.

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

Wight Goodman Wight Goodman, Patient was admitted to the floor last night from the ER for an orbital fracture. He was hit in the left eye by a softball yesterday. Apparently he was pitching, and the batter hit a line drive hitting him in the right side of the face. They applied some ice to his face, and he decided to go to the post game keg party instead of coming to the ER. The patient stated that there was significant swelling, but his vision was fine, and the pain was controlled with beer and 800mg of Motrin. He was unable to sleep later in the evening as the pain became worse, and his vision became more impaired. The Maxillofacial surgeon was consulted, and they will see him this morning. They were not concerned as his intraocular pressure was normal in the ER. There is significant edema and discoloration to the left side of his face, and his left eye is almost completely swollen shut. His visual acuity is diminished, and the whites of his eyes are hemorrhaged. His pain has been well controlled with IV morphine 4 mg, q3 hours. He has a 20g SL to his right hand, that was started in the ER. He has no other health concerns. He's being admitted for pain control, close observation of his intralocular pressure, and head injury.

Educational Needs: Increased Fall Risk: Increased Health Change: Increased Neurological: Normal Pain Level: Increased Psychological Needs: Normal Physiological- Acute Pain: True Bleeding, Risk for: True Impaired Comfort: True Safety- Deficient Knowledge: True Infection, Risk for: True

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 scale for coverage. ADA diet, intake 25%. Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. Patient and family upset regarding dx. Dr. Donofrio

Educational Needs: Increased Fall Risk: Increased Health Change: Increased Pain Level: Increased Psychological Needs: Increased Sensorium: Normal Physiological - Bleeding, Risk for: False Chronic Pain: True Constipation, Risk for: True Decreased Cardio Tissue Perfusion: False Imbalanced Nutrition: True Impaired Skin Integrity: False Safety - Anxiety: True Deficient Knowledge: False Fear: True Grieving: True Impaired Home Maintenance management r/t client or family: False Ineffective Self-Health Management: False Esteem - Disturbed body: False Hopelessness: True Noncompliance: False Powerlessness: True

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

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

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 requesting to see her family. She states that she does not want to die alone.

Educational Needs: Increased Fall Risk: Normal Health Change: Increased Neurological: Normal Pain Level: Increased Psychological Needs: Increased Physiological- Acute Pain: True Deficient Knowledge: True Grieving: True Impaired Comfort: True Safety: Infection: True

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.

Physiological- Acute pain: False Impaired comfort: True Impaired mobility: False Safety- Deficient knowledge: True Fall, risk for: False Grieving: False Sexuality: True

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 left side of his face. Some hair on the left side of his head has been burned off, as well. His left humerus is fractured and splinted. It was diagnosed by a portable X-ray and quickly splinted by the ER staff. He also has metal fragments on his left side on his leg arm and torso. He is having some difficulty hearing and complains of ringing in his ears. It is unclear if he lost consciousness. He is complaining of pain in his left arm, and pain in his left chest when he tries to take a deep breath. He does not have an IV nor is he on oxygen. Vital Signs: B: 160/92, P: 96, R: 22, SpO2: 98, T: 98.9F, 37.1C.

Physiological- Acute Pain: True Bleeding: True Impaired comfort: True Nausea: False Safety- Deficient knowledge: True Fall, risk for: True Grieving: False

Carlos Mancia Scenario 1 Mr. Mancia is a non-English speaking patient and is fearful of being discovered as an illegal immigrant. Upon entering the room with a translator to admit him to the hospital, he is asked for address and phone number but refuses to comply. Scenario 2 Upon entering the room, you wash/glove hands. Following isolation precautions, you notice several family members are by his bedside and none of them are wearing face masks as requested by the sign on the door. Scenario 3 Before entering Carlos Mancia room to administer his antipyretic medication for his recent temp of 101.2 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.

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

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, the last place she saw him was right before the explosion. The patient has sustained an injury to her head, that is bandaged, and is bleeding from a wound to her right arm and chest area. She is having some difficulty breathing. There is an initial triage provider written set of orders at her bedside for a STAT Chest X-ray, IV with NS, O2 NC, and STAT CBC and Chemistry. Scenario 4 The patient has a pneumothorax that requires a chest tube placement. The Physician tells you to have everything ready including a 22 French chest tube, and he will be in shortly to position the chest tube. You notify the charge nurse that you have never taken part in inserting a chest tube. The charge nurse tells you she will send someone to assist you, and to get out 2mg of Versed to have ready to sedate the patient at time of procedure. Patients vital signs are BP: 100/58, P: 106, R: 28, PaO2: 92%, T: 97.1 F, 36.2 C. Scenario 5 The charge nurse tells the nurse to take Mr. Burgundy to the floor, because his room is now ready. Mr. Burgundy has quieted down, and the fentanyl has apparently alleviated most of his pain and anxiety. Mr. Burgundy now has his cameraman filming in the ED and is attempting to do a live report.

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 -Explain to Mr. Burgundy that space in the ED is allocated based off of patient need -Inform Mr. Burgundy that he cannot report from the ED, as patient privacy is strictly protected by HIPPA -Ask Mr. Burgundy to lower his tone as it can be disturbing to other patients -Reassure patient that he will be moved to a private room as soon as possible -Reassess patient's physical status prior to leaving him in the hallway Scenario 3 -Assess patient's ABC (airway, breathing, circulation) -Take initial vital signs (room air Pulse Ox) -Place patient on O2 Nasal Canula -Start IV -Set-up for stat portable chest x-ray Scenario 4 -Explain procedure to the patient -Place patient on 100% O2 -Ensure there is suction in the room, and check -Obtain chest tube tray and set-up pleurovac -Reassess patients' vital signs, and place on q5 minutes continuous monitoring Scenario 5 -Instruct Mr. Burgundy and his cameraman to stop immediately -Notify charge nurse -Call security for assistance and compliance officer -Transport Mr. Burgundy to his room -Complete incident report

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 believes the nursing staff is trying to kill her. Her Temp is 101.3, BP 98/58, P 98, R 22, and PaO2 86%. The PCT is requesting to be relieved as the patient keeps pulling at the PCT's mask to see who she is. The nurse calls the attending provider requesting that Ms. Barkley be transferred to the ICU, but there are no rooms available. Instead the nurse is told to put the patient on telemetry and call RT for a CPAP trial. Scenario 4 The patient continues to be combative while attempting to initiate the CPAP trial. Healthcare provider has ordered Haldol in order to sedate the patient. Vital signs are deteriorating, BP 90/58, P 116, R 28, PaO2 85%, T 102.0 Enter the room after taking vital signs. Scenario 5 Ms. Barkley requires emergency intubation, and the Healthcare Provider on scene suggests that the patient did not want to be intubated. You, the nurse, are concerned because the family asked for everything to be done and the patient never signed a do not resuscitate order (DNR). The patient has now been sedated, and RT is temporarily maintaining their saturations with effective valve mask ventilation.

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.

Lithia Monson Scenario 1 You arrive in room to find Ms. Monson talking to herself. Upon assessment, you determined that she is confused to person, time, and place but is easily directable. Scenario 2 A special lowbed has been ordered that will lower to the ground. The bed arrives tomorrow. You are concerned about preventing the patient from falling. Scenario 3 A few hours after speaking with the sitter about the patient needing complete observation, you notice the sitter outside of the room talking on the phone. Upon entering the room, the patient appears to be trying to get out of bed Scenario 4 Prior to changing shift, you enter the patient's room to complete a full assessment, and Ms. Monson is now crying asking to for someone to take her home! 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.

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

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 CP but not completely. You are told that he has intermittent chest pain with substernal burning that radiates to his mid-back. The patient describes this pain as a heavy pressure with intermittent stabbing. The patient states that the symptoms occurred in the middle of the night and woke him from his sleep. The pain makes him short of breath. The heartburn has become worse since he started treatment for his URI. His CP is 7/10 and his BP is 165/96, P 92, R 18, SaO2 98 on 2L NC. He is questioning the nurse as to why he has been admitted for heartburn. He has not had his BP medication today. Scenario 2 Mr. Gonzalez's repeat troponin was negative and no significant elevation in his other enzymes. He has been ruled out for an MI. He told the nurse that he has had some changes in his bowel habits and his stools have been very dark. The patient has been scheduled for an EGD today and has an order for Omeprazole (Prilosec) and Carafate (sucralfate). When the nurse enters the room later that day to inform him that the procedure is scheduled for 1430, they see Mr. Gonzalez is sitting in front of a lunch tray. He is excited and tells the nurse he is starving and glad that he finally gets to eat. Scenario 3 Mr. Gonzalez has returned from his EGD and is still sleeping from the sedation. He was initially sedated with versed 2mg, and Fentanyl 100 mg by the EGD nurse, but the patient was not tolerating the procedure, so anesthesia was called to administer propofol. The nurse was told by the gastroenterology nurse that they really struggled before they called anesthesia and they may have caused an esophageal abrasion. Due to this, the provider would like him to stay in the hospital for observation. The dinner tray is waiting for the patient in his room, and the nurse notices it is a regular diet. His VS are BP 122/64, P 89, R 12, SpO2 93%. Scenario 4 The nest morning the gastroenterologist informs Mr. Gonzalez that his EGD confirmed a diagnosis of Barrett's esophagus with Dysplasia. The provider explains that it is a pre-cancerous stage in where the cell develops abnormal features. However, these abnormal cells do not have the capability to spread to other parts of the body. Biopsies were sent to determine the treatment. The patient is being prepared for discharge and his IV has been removed. When the nurse retunes to the room the patient tells the nurse that when he went to the bathroom he became very lightheaded. He also complains that his throat is still very sore. The nurse performs tilt test, Patient vital signs lying flat, BP 118/62, P 92, R 20, T 98.5, SpO2 97. Sitting, BP 109/60, P 114, Standing the patient becomes very lightheaded and the nurse has them lay back down. The provider advises the Nurse to draw a stat CBC, give a liter bolus of NS, and repeat CBC. Scenario 5 Mr. Gonzales H/H is 12.7/38. His orthostasis is normalized after a second liter of NS was administered. The pathology report shows no cancerous lesions. Since the finding was low-grade dysplasia and is considered the early stage of precancerous changes, the gastroenterologist recommends another endoscopy in six months, with additional follow-up every six to 12 months. He warns the patient that if he does not comply with the treatment and preventive measures, he will need other treatments that may include. Endoscopic resection, which uses an endoscope to remove damaged cells to aid in the detection of dysplasia and cancer. Radiofrequency ablation, which uses heat to remove abnormal esophagus tissue. Radiofrequency ablation may be recommended after endoscopic resection. Cryotherapy, which uses an endoscope to apply a cold liquid or gas to abnormal cells in the esophagus. The cells are allowed to warm up and then are frozen again. The cycle of freezing and thawing damages the abnormal cells. After leaving the room the provider tells the nurse that he hopes that he scared him into compliance with the treatment options. The patient will be discharged today, and he will be ordering new prescriptions. When you enter the room, the patient is having chest pain again, and they are pale and diaphoretic.

Scenario 1 -Tell the patient that they are being admitted to r/o any cardiac issues -Perform admission assessment -Tell the patient to call immediately if the chest pain gets worse or they become short of breath -Explain to the patient that because of his weakness and unknown cardiac status as well as the IV, he is a fall risk and should not get out of bed without assistance. -Ensure the bed is in lowest position, the side rails are up, the call light is in reach, and ask the patient if they need anything before you leave the room Scenario 2 -Explain to the patient that he has a procedure, and he cannot eat. -Reinforce the risk if patient has not been NPO and ask the patient when the last time they ate. -Administer the medication with a small sip of water and place an NPO sign at the entrance of the patient's room. -Assess if the contents of lunch tray are intact. -Remove the lunch tray and ensure pre-operative consent has been signed. Remind the nursing staff that the patient is NPO. Scenario 3 -Assess patient LOC, by walking patient and asking them to take deep breaths. -Elevate head of bed and place the patient on Pulse oximetry. -Reapply the NC that he was admitted with at 2L -Remove the dinner tray and make sure the diet is soft food. -Reassess patient q 5 minutes until awake, then 15 minutes until they are fully awake (not Drowsy). Scenario 4 -Restart the IV and draw CBC -Give NS liter bolus -Recheck Tilts after the NS bolus is complete.T -Remind patient to call for help is he need to get up and provide patient with a urinal. -Draw a repeat CBC per HCP order to determine current Hemoglobin status Scenario 5 -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 the patient's anxiety level while using therapeutic communication to decrease patients' stress. -Verify that discharge orders have been written, provide discharge instructions, and in inform provider about the chest pain.