Clinical 2

Estelle Hatcher, 31yr-old, r/o appendicitis, 1st day post-op appendectomy; No known allergies (NKA); Vital signs - Temp 101.2, BP 108/74, P 92, RR 20, SaO2 99%, alert and cooperative. Wound site clean, dry and intact NPO, NG-tube to low continuous suction. IV maintenance fluids with D5 1/2 NS with 20 KCL @ 125ml/hr in left forearm. Ambulates with minimal assistance. Family at beside. Dr. Sangerstien

Educational Needs Increased acuity Fall Risk Increased Acuity Health Change Increased Acuity Pain Level Increased Acuity Psychological Needs Normal Acuity Sensorium Normal Acuity

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

Educational Needs Increased acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Increased acuity Psychological Needs Increased acuity Sensorium Increased acuit

Kathy Gestalt, 33yr-old, Dx- second day post-op open right Tibia/Fibula fracture, plaster cast in place on 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 reluctance regarding walking on leg. Diet as tolerated, up ad lib after gait training. Crutches at bedside adjusted for height. Dr. Anderson

Educational Needs Increased acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Increased acuity Psychological Needs Increased acuity Sensorium Normal acuity

Robert Sturgess, 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 acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Increased acuity Psychological Needs Increased acuity Sensorium Normal acuity

Ann Rails, 38 years old, c/o back pain, non-significant past medical history. No known allergies (NKA). Vital signs -BP 124/82, Temp 98.2, P 84, RR 22, SaO2 96%. Pain and numbness in legs for one week. Abnormal left leg weakness, gait unsteady, 5/10 on numeric pain scale. Neuro WNL, except leg pain upon movement. Activity as tolerated with assistance. D/C plan- decrease pain and restore normal gait. Regular diet. Dr. Suculo

Educational Needs Increased acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Increased acuity Psychological Needs Normal acuity Sensorium Normal acuity

John Duncan, 56yr-old male, Dx- Gastroenteritis, returned yesterday from Cancun, c/o intractable diarrhea, weak, pale, and refusing to eat. No known allergies (NKA). Non-significant past medical Hx. Vital signs Temp 99.4, BP 106/72, P 96, RR 20, SaO2 91%. Neuro WNL's, alert and cooperative. IV maintenance fluids with D5 1/2 NS at 125ml per hour in left forearm. c/o headache- medicated with Lortab 5mg PO at 0900, takes Lomotil 10ml PRN q 4 hours last dose at 0834. Stools are decreasing but patient remains very weak. Wife at bedside. Diet as tolerated. Dr. Jones.

Educational Needs Increased acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Increased acuity Psychological Needs Normal acuity Sensorium Normal acuity

Ramona Stukes, 69 yr-old, third day post-op cholecystectomy. Non-significant past medical history. No known allergies (NKA). Vital signs -Temp 98.6, BP 114/62, P 100, RR 20, SaO2 94%. Neuro WNL, alert, and cooperative. Skin warm and dry, daily dressing changes, T-tube without drainage. NG tube to low suction possibly D/C'd today after Dr. Levine rounds. Today's incentive spirometry Tidal Volume is 1250ml, improvement over yesterday's 900ml. NPO with small amount of ice chips only. Today's weight 226. IV D5 1/2 NS with 20 KCL @ 125 ml/hr in left forearm. Last pain medicine 2hrs ago at 1300(Demerol 50mg/ Zofran 4mg IV). Ambulates with assistance. Dr. Levine

Educational Needs Increased acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Increased acuity Psychological Needs Normal acuity Sensorium Normal acuity

Tom Richardson, 46yr-old. Dx- urinary stones with 3 episodes/5yrs. Allergic to sulfa drugs. Vital signs -Temp 98.4,BP 178/105, P 112, RR 28, SaO2 94%; Neuro- WNL's. Skin warm and pale. Generalized weakness, blood tinged urine and severe pain upon urination, GI- n/v. Clear liquid diet. Strict I&O and strain all urine, filters in bathroom. Patient demonstrates urine strain procedure. Severe pain (10/10) medicated q 30 minutes x4 with IV Morphine 2mg with little relief. IV D5 1/2 NS @150ml/hr. Dr. Small at bedside with patient and family. Stat lithotripsy treatment ordered. Awaiting transport.

Educational Needs Increased acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Increased acuity Psychological Needs Normal acuity Sensorium Normal acuity

Viola Cumble, 92yr-old, second day post-op hip repair, Allergic to Penicillin. Vital sign Temp 98.4, BP 136/78, P 72, RR 20, SaO2 97%. Normal Sinus Rhythm on telemetry. Alert and cooperative. No weight bearing today. Skin warm and dry, may sit up on edge of bed today. Needs frequent reminding due to determination to do things herself without assistance. Wound clean dry and intact. Regular diet. Dr. Starks

Educational Needs Increased acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Increased acuity Psychological Needs Normal acuity Sensorium Normal acuity

Sarah Getts, 77 yr-old, Dx- Chronic Renal Failure, admitted with hyperkalemia (5.9, Eq/L)/hyponatremia (128mEq/L). No known allergies (NKA). Vital signs -Temp 98.8, BP 102/76, P 102- irregular, RR 22, SaO2 90%, cardiovascular on telemetry with Sinus irregular rhythm. Disoriented to time and place, speech slurred. Pupils PERRLA, eyes clear. 20 ga. Hep-Lock in right forearm, skin warm and dry, generalized weakness with recent weight loss. 50% intake. High fall risk. Renal diet. Family in room with patient very concerned. Dr. Brown

Educational Needs Increased acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Normal acuity Psychological Needs Increased acuity Sensorium Increased acuity

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 acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Normal acuity Psychological Needs Increased acuity Sensorium Normal acuity

Marcella Como, 38 yr-old, Sexual Trauma Victim (Rape), unknown assailant. Non-significant past medical Hx. No known allergies (NKA). Vital signs -Temp 98.2, BP 94/60, P72, RR 22, SaO2 99%. Multiple abrasions, bruising Head, chest, and inner thigh. Isolative, appears fearful, crying, and refusing to see her husband. SANE nurse to make second visit today. Awaiting diagnostic labs. Taking HIV Meds prophylaxis. Social worker with patient this morning. Diet as tolerated. Dr. Roopes

Educational Needs Increased acuity Fall Risk Normal acuity Health Change Increased acuity Pain Level Increased acuity Psychological Needs Increased acuity Sensorium Normal acuity

Arthur Thomason, 56-year-old MVA victim, fourth day post op with a splenectomy and femur repair. He is experiencing new onset of shortness of breath and has a nasal cannula with 2L of Oxygen in place. He is restless with slight confusion but is easily orientated with attempts from nurse. Temperature spiked during the night to 102.4, BP now 146/94 which is slightly elevated, respirations at 30 bpm and slightly labored, heart rate 102 versus 84 from last night shift. Skin cool to touch and appears pale. His coughing, to clear his airway, appears ineffective. Recent chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes. Recent blood gases demonstrate falling PaO2 (hypoxemia) and increasing CO2 (Hypercapnia). Mr. Thomason is anxious and is obviously worsened from the shift before in overall condition.

Educational Needs Increased acuity Health Change Increased acuity LOC Increased acuity Pain Level Increased acuity Psychological Needs Normal acuity Safety Increased acuity

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%.

Educational Needs Increased acuity Health Change Increased acuity LOC Normal acuity Pain Level Increased acuity Psychological Needs Normal acuity Safety Increased acuity

Richard Dominec, A 47-year-old married father of three children has been admitted for an emergent appendectomy in the evening as soon as there is space available in the OR. He is currently febrile with temperature 100.8, HR 99, BP 135/96, RR 20, PaO2 96%, nauseated with no vomiting, rebound tenderness in right lower quadrant, has elevated WBC's and surgeon feels this will be uneventful even though he has just been diagnosed with AIDS this past week. His overall health is good, and he has known he has been HIV positive for the past five years. He has been taking his HIV medication daily. Recently he manifested an unusual black lesion on his thigh and developed an opportunistic fungal mouth infection which was treated successfully. The lesion was identified as Kaposi's Sarcoma. Now, meeting the CDC definition, he has full blown AIDS but is asymptomatic at this time. Mr. Dominec has a male partner and has been married for the past ten years and share their three children to the marriage.

Educational Needs Increased acuity Health Change Increased acuity LOC Normal acuity Pain Level Increased acuity Safety Increased acuity

Estelle Hatcher

Physiological Activity Intolerance False Acute Pain True Diarrhea False Electrolyte Imbalance, Risk for True Impaired Comfort True Impaired Mobility False Safety Deficient Knowledge True Fall, Risk for True Fear False Ineffective Self-Health Management False Infection, Risk for True Sleep Deprivation False

Sarah Getts

Physiological Acute Pain False Deficient Fluid Volume False Electrolyte Imbalance True Imbalanced Fluid Volume, Risk for True Impaired Skin Integrity, Risk for False Ineffective Renal Perfusion, Risk for True Safety Acute Confusion True Disturbed Sensory Perception False Fall, Risk for True Sleep Deprivation False Love and belonging Anxiety False Failure to Thrive True

Richard Dominec

Physiological Acute Pain True Bleeding False Chronic Pain False Constipation False Knowledge Deficit True Nutrition True Risk for Infection True Skin integrity at risk True Love and Belonging Compromised Family Coping False Fear/Anxiety True

Ann Rails

Physiological Acute Pain True Bleeding, Risk for False Chronic Pain False Impaired Comfort True Impaired Mobility True Nausea False Safety Deficient Knowledge False Disturbed Sensory Perception True Fall, Risk for True Grieving False Infection, Risk for False Peripheral Neurovascular Dysfunction True

Viola Cumble

Physiological Acute Pain True Bleeding, Risk for True Constipation False Impaired Mobility True Impaired Skin Integrity, False Ineffective Peripheral Tissue Perfusion False Safety Acute Confusion False Deficient Knowledge False Fall, Risk for True Ineffective Self-Health Management True Infection, Risk for True Peripheral Neurovascular Dysfunction False

Kathy Gestalt

Physiological Acute Pain True Chronic Pain False Impaired Mobility True Impaired Skin Integrity, Risk for True Ineffective Peripheral Tissue Perfusion False Self-Care Deficit False Safety Anxiety True Deficient Knowledge True Fall, Risk for True Grieving False Impaired Home Maintenance Management r/t Client or Family False Peripheral Neurovascular Dysfunction False Esteem Decisional Conflict True Deficient Diversional Activity False Disturbed Body True Hopelessness False

Tom Richardson

Physiological Acute Pain True Electrolyte Imbalance False Imbalanced Nutrition False Impaired Mobility, Risk for True Impaired Skin Integrity, Risk for False Impaired Urinary Elimination True Safety Fall, Risk for True Sleep Deprivation False

Marcella Como

Physiological Acute Pain True Impaired Mobility False Impaired Urinary Elimination False Readiness for Enhanced Immunization Status True Safety Chronic Confusion False Fall, Risk for False Fear True Grieving True Infection, Risk for True Sleep Deprivation False Love and belonging Anxiety True Body Image, Disturbed False Chronic Sorrow False Compromised Family Coping True Powerlessness False Social Isolation True Esteem Decisional Conflict False Ineffective Coping True Noncompliance False Rape-Trauma Syndrome True Self-actualization Disturbed Energy Field True Spiritual Distress False

Arthur Thomason

Physiological At Risk, Impaired Comfort False Impaired Gas Exchange True Ineffective airway clearance True Shock False Safety Chronic Confusion False Love and Belonging ExplanationAnxiety/ fear True Failure to Thrive False

Virginia Smith

Physiological Bleeding False Impaired Gas Exchange False Ineffective breathing pattern False Pain, Acute True Physical Mobility, Impaired True Skin integrity, impaired True Safety Acute Confusion False Knowledge Deficit True Esteem Disturbed Body Image True Hopelessness False

Robert Sturgess

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

Ramona Stukes

Physiological Bleeding, Risk for True Constipation False Deficient Fluid Volume, Risk for True Dysfunctional Gastrointestinal Motility False Imbalanced Fluid Volume False Impaired Mobility True Safety Anxiety False Fall, Risk for True Ineffective Self-Health Management False Infection, Risk for True

Lithia Monson

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

Carlos Mancia

Physiological Dysfunctional Gastrointestinal Motility False Electrolyte Imbalance False Fatigue True Impaired Gas Exchange True Impaired Mobility False Ineffective Airway Clearance True Safety Anxiety True Deficient Knowledge True Fall, Risk for False Fear True Hypothermia False Impaired Home Maintenance Management False Love and belonging Chronic Sorrow False Social Isolation, Risk for True Esteem Decisional Conflict False Noncompliance True Self-Actualization Readiness for Self-Care Enhancement True Spiritual Distress False

John Duncan

Physiological Deficient Fluid Volume True Electrolyte Imbalance, Risk for True Excess Fluid Volume, Risk for False Fatigue True Nausea False Self-Care Deficit False Safety Fall, Risk for True Infection, Risk for False Esteem Ineffective Coping False Noncompliance True

Virginia Smith Scenario 1 Mrs. Smith shares with you that even though she signed the operative consent she was not sure if this was the right surgical procedure for her. Her husband who is present states, "I thought it was just a lumpectomy she was having this morning." Scenario 2 It is now two weeks later; Mrs. Smith has returned. You question her while reviewing her operative consent and determine that everything is correct. She receives the pre-op medication. Her husband and children remain with her in the surgical holding area awaiting transport to the OR. Scenario 3 Mrs. Smith's surgery has now ended. You now arrive in the recovery unit one hour post-surgery and you are told that the surgery went well. Her chart reports she was extubated upon arrival to the recovery area, received three units (3000 mL) of fluid, receiving O2 @ 4L via nasal cannula, has Foley Catheter in place draining QS clear yellow urine, responds to verbal stimulation, chest dressing in place remains dry and intact, and has just received a small dose of IV morphine for pain. Vital signs are: B/P 112/78, temp. 97.4, Resp 16 and Pulse Ox 94%. Scenario 4 You are about to call the Surgical ICU and give report. What order are you providing the information to the receiving nurse? Scenario 5 You are the now the Surgical ICU nurse assigned to her. She has just been transported from recovery. List the nursing care order.

Scenario 1 Ask patient to explain to you what procedure she was expecting to have this morning. If patient statement differs from the surgical consent she has signed, notify surgeon immediately Stay with patient for surgeon's arrival to explain intended surgical procedure Contact head nurse or supervisor in the OR to evaluate new situation Procedure is canceled for the day and rescheduled later allowing for new consent. Scenario 2 Therapeutic communicationT Validate NPO Status Encourage to ambulate with assistance to void if needed Connect telemetry Provide a few chairs if possible for her family to also be comfortable Scenario 3 Vital signs taken by automatic B/P Cuff q 15 minutes Assess Talk with her stating surgery is over and she did great. Allow husband to come into recovery for a quick one-minute visit. Document and prepare to transfer to Surgical ICU Scenario 4 Provide Operative summary of type of procedure, IV fluid and pain status. Present health assessment including B/P and LOC and dressing. Report current urinary output quantify per hour and color of urine Request time she can arrive and staff to help with transfer Explain to her family and provide contact information. Scenario 5 Full assessment of patient. Provide for physical and thermal comfort. Therapeutic communication. Begin post op education for day one Notify family as to when they may come and visit.

John Duncan Scenario 1 As you enter the room, Mr. Duncan is refusing to eat foods from bland diet. Scenario 2 Mr. Duncan is now complaining of feeling "dizzy" when he stands. Scenario 3 Several hours later, Mr. Duncan is now complaining of nausea. Scenario 4 Two hours later, Mr. Duncan is asked how frequent his stools have been today. He replies, "six times in the past four hours". He also states he is feeling weak. Scenario 5 Mr. Duncan's wife meets you in hall asking what she could bring her husband to eat from home.

Scenario 1 Assess intake and output and possible reasoning Construct dietary consult (plan) Acquire daily weight and food intake Evaluate outcome of dietary plan Scenario 2 Full assessment including both lying/standing Check input/output for possible dehydration Teach patient about safety when getting out of bed Document findings Scenario 3 Wash and glove hands Provide emesis basin/cloth Vital assessment Administer antiemetic medication Evaluate medication effectiveness Scenario 4 Vital assessment Assessment of bowel movement Administer protocol antidiarrheal medication Document results/findings Include patient condition change in shift report Scenario 5 Inform and educate spouse of dietary orders Evaluate/modify plan of care Assess food consumption and intake and output Document findings/results

Kathy Gestalt Scenario 1 Ms. Gestalt is second day post-op and has requested to get out of bed and to ambulate to bathroom. Scenario 2 Ms. Gestalt is now complaining of fever and chills. Scenario 3 After 24 hours, Ms. Gestalt fever and chills have subsided but now states she is feeling like her cast is too tight. Scenario 4 Ms. Gestalt capillary refilling is now 6 secs below cast site, extremity is swollen and cold to the touch. Scenario 5 You enter room and find Ms. Gestalt crying because she has just learned her medical insurance has lapsed and she is already two months behind on her car payments.

Scenario 1 Check pedal capillary refill Educate patient Evaluate understanding Adjust crutches Assist patient out of bed Scenario 2 Wash and glove hands Vital assessment Administer antipyretic meds Verify call light/bed safety precautions Document results/findings Scenario 3 Inspect cast site Assess toe movement and capillary refilling Notify doctor if condition is abnormal Document Results/Findings Scenario 4 Elevate Extremity Assess pain Educate patient regarding condition Notify lead nurse/doctor Retrieve cast removal tool Scenario 5 Use therapeutic communication/Active Listening Notify lead nurse/doctor Consult Social Service Evaluation patient after consult Document Results

Carlos Mancia Scenario 1 Mr. Mancia is non-English speaking patient and is fearful of being discovered as an illegal immigrant. Upon entering the room with a translator to admit him to the hospital, he is asked for address and phone number but refuses to comply. Scenario 2 Upon entering room, you wash/glove hands. Following isolation precautions, you notice several family members are by his bedside and none of them are wearing face masks as requested by sign on door. Scenario 3 Mr. Mancia's vital signs upon assessment are Temp 101.2, P 94, RR 20, BP 122/82, SaO2-91%. Scenario 4 The sister of Mr. Mancia calls from home to speak with you. She shares concern about patient's wife who is now coughing and having night sweats. Scenario 5 Mr. Mancia is holding Catholic Rosary in hand and is crying as you enter the room.

Scenario 1 Don Personal Protective Equipment Allow for non-compliance of request Do not probe further Verify call Light/bed safety precautions Document results Scenario 2 Obtain translator Offer masks to visitors Educate patient Evaluate understanding Obtain Spanish signs & brochure Scenario 3 Obtain translatorT Wash and glove hands Gown and mask Administer antipyretic medication Encourage fluids Scenario 4 Educate caller regarding HIPAA Evaluate caller understanding Refer call to contact health department Notify doctor Document conversation Scenario 5 Obtain translator Use therapeutic communication/Active Listening Educate patient Evaluate learning Document teaching moment

Robert Domenic Scenario 1 After two hours, Mr. Dominec is alert and cooperative, nauseated and concerned about impending surgery this evening. His partner is at the bedside asking, "how much longer will he have to wait until taken to surgery?" Scenario 2 Mr. Dominec had his surgical procedure and is doing great. It is now the second day post op and he is given discharge information. His partner is not with him at this time but will arrive soon to facilitate his discharge home. Scenario 3 Mr. Dominec is waiting for his partner to arrive to take him home and you notice he has a dry unproductive cough and trouble splinting with a pillow at his operative site. You take his vital signs which are: Temp 101.3, Pulse 88, Resp 24, B/P 116/84. Scenario 4 Mr. Dominec decides he does not want to see Infectious Disease doctor about his new cough. He chooses to go home and see the doctor tomorrow in his office. He states, "This is not serious." Scenario 5 Mr. Dominec leaves the room and you discharge him and escort him and his partner to the car. You return to the break room on your floor. Your coworkers are asking you questions about Mr. Dominec. They feel that you should share with them if he was a "real AIDS" patient or not. They were also concerned about the next patient going into that room and the use of the lavatory. They wanted to know and pressure you for the information. Two housekeepers, who were refusing to clean the room, are in the break room. Your response to all of them would be:

Scenario 1 Perform full assessment and provide anti-nausea medicine. Provide comfort in pre-surgical room Mr. Dominec. Check surgical consent for correct procedure and make sure operative site in marked. Inform his partner that everything is being done to keep him comfortable. Scenario 2 Educate about recovery from appendectomy and care to wound. Discuss his understanding about the plan of care. Discuss follow up with his doctor. Offer assistance in providing more information about treatment options for newly diagnosed AIDS patients. Determine from medical record if partner is aware of his recent AIDS diagnosis. Scenario 3 You discuss this cough with Mr. Dominec to determine how long he has had it. Notify doctor of change in condition in particular: unproductive cough and low-grade fever. Explain to Mr. Dominec your concern for this opportunistic infection and usual treatment. Explain that he will probably not be going home at least until his doctor sees him. Notify charge nurse that discharge will probably not occur today. Scenario 4 Inform patient about the progression and risk a PCP infection has for a patient with AIDS. Obtain and provide the infectious disease doctor's contact information for him. Encourage Mr. Dominec to discuss with his partner his best treatment options. Take vital signs before leaving the hospital again. Document and provide copy for Mr. Dominec to share with his follow up appointment tomorrow. Scenario 5 This information is HIPAA protected and you cannot share anything with them. Remind staff that Universal Precautions are practiced at this hospital for all patients regardless of known infectious diseases. Leave to break room and not continue in conversation. Report this activity immediately to the hospital privacy officer Report to charge nurse/ head nurse the need for staff education.

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 There is an order to apply a waist belt restraint if needed. You determine to apply the restraint now. Scenario 3 Ms. Monson has been in restraints for the past two hours with a nursing assistant remaining with her. You arrive in room to check on her, after washing hands. Scenario 4 After 3 hours, Ms. Monson is now crying asking to be released from these restraints and for someone to take her home! Scenario 5 In reassessing Ms. Monson, her vital signs are: BP -106/82, Temp-98.2, P-106, RR-18, SaO2-88.

Scenario 1 Perform neuro assess Reorient Patient to person, place, & time Assess for fall risk Offer nutrition/toilet Scenario 2 Explain reason for assessment and procedure Vital sign assessments Apply restraint Perform circulatory evaluation Request sitter/family member to bedside Scenario 3 Employ therapeutic communication: present reality Release restraints/full range of motion Reapply restraints Perform circulatory evaluation Document results Scenario 4 Use therapeutic communication/active listening Attempt to orient to person, place, and time Perform circulatory evaluation Offer nutrition and/ or toileting Document results Scenario 5 Check monitor Apply nasal cannula Vital re-assessment Notify lead nurse/doctor Remain with Patient

Arthur Thomason Scenario 1 You enter his room and recognize that Mr. Thomason appears to be talking to himself and appears confused. Scenario 2 Mr. Thomason appears now better oriented and MD arrives unexpectedly to examine him. Scenario 3 You enter room one hour after the physician has left the patient. Your notice Mr. Thomason is lying supine, appears slightly cyanotic in his lips, is exhibiting more effort to breathe, and is increasingly restless. Lung sounds are worse. Scenario 4 Rapid Response team arrived including anesthesia. The MD on site makes the decision to intubate the patient and start ventilatory assistance and move the patient to Respiratory Intensive Care. Scenario 5 Family arrive one hour after event to his prior room and find Mr. Thomason's room is empty and have no idea of the events that have just occurred. You, his prior nurse, notice the family and respond to them.

Scenario 1 Replace oxygen nasal cannula that had become disconnected Therapeutic communication Assess Notify doctor and charge nurse Scenario 2 Remind physician to wash his hands before examining the patient Explain to physician what interventions you have recently initiated Assist physician in physical exam of patient Obtain recent chest X-ray reports and recent ABG's for physician to review Reassure patient and help explain any new orders from physician to patient Scenario 3 Tap patient and ask, "Are you okay?" Elevate head of bed Call Rapid Response protocol initiated Start secondary large bore IV line Remain with patient and reassure Scenario 4 Provide verbal report to team members who respond to rapid response Emergency intubation and assisted breathing is provided for Mr. Thomason Assume role in response team of documenter Obtain patient record and follow patient as he is transferred to ICU Provide information for MD to call family at home and explain what has just happened Scenario 5 You explain that his condition has worsened and now he has been taken to ICU. You explain that he is receiving a higher level of care and was he was sedated before leaving the floor to make him more comfortable. You have them remain with you, seated in comfortable place, while you call ICU and attempt to locate physician for them. You escort them with you to the ICU. You call his doctor to inform him the family has arrived.

Ann Rails Scenario 1 You enter patient's room. After washing and gloving hands, you then identify yourself and the patient, Ann Rails. You notice she is crying and is expressing fear that she "will always have this pain and numbness" and she doesn't think she can cope. Scenario 2 Ms. Rails was medicated with hydrocodone 5 mg PO two hours ago and is now complaining of pain (8/10 pain scale). Scenario 3 Ms. Rails shares with you her fear of being discharged home to an abusive husband. Scenario 4 Upon entering the room, you find Ms. Rails sleeping. She has received a dose of Hydrocodone for PRN pain 20 minutes ago. Scenario 5 Ms. Rails states that she has not had a bowel movement (BM) in the past two days.

Scenario 1 Use therapeutic communication/Active Listening Educate patient regarding patient care Evaluate patient learning Place call light and check bed for safety Document results and findings Scenario 2 Wash and glove hands Assess Provide comfort measures Notify doctor Document results and findings Scenario 3 Listen to patient concerns Reassure patient of options Notify lead nurse/doctor Contact Social Services Document results Scenario 4 Wash and glove hands Visual assessment Do not disturb Verify Call Light/Bed Safety precautions Document results Scenario 5 Assess for bowel sounds Encourage fluids/fiber/ambulation Evaluate patient understanding Attain fluids/fiber diet and assisted ambulation Document results

Marcella Como Scenario 1 Ms. Como is first day after sexual assault. Upon entering the room, she is quiet and shows little emotion. Scenario 2 Later in morning care, Ms. Como requests to take a shower stating she feels 'dirty'. Scenario 3 In the afternoon, Ms. Como is stating that she does not want to see her husband or any visitors. (Think Therapeutic Communication) Scenario 4 Marcella Como is now more talkative and shares with you that she is going to cooperate and wants to press charges against the assailant. Scenario 5 Marcella is very worried about STD's and possible pregnancy.

Scenario 1 Use therapeutic communication/Active Listening Full Assessment Provide emotional support Documentation Scenario 2 Use therapeutic communication/Active Listening Educate patient Provide supplies and needed instructions. Offer to Assist Scenario 3 Use therapeutic communication/Active Listening Ask open-ended questions Seek clarification Summarize discussion Scenario 4 Restate or paraphrase patient statements Acknowledge patient's decision Review plan of action Notify social services Document process Scenario 5 Review Labs Educate Patient-STD's and pregnancy Provide emotional support Discuss Support Groups

Ramona Stukes Scenario 1 Mrs. Stukes is a failed laparoscopic cholecystectomy that resulted in a bowel resection with a temporary ileostomy in place. Now, third day post-op, Mrs. Stukes appears sad and depressed upon entering the room. Scenario 2 Mrs. Stukes is feeling nauseated. Scenario 3 Mrs. Stukes's appliance is leaking for the fourth time today and has been changed and reapplied each time. She is frustrated and overwhelmed with the new appliance not working properly. Scenario 4 Mrs. Stukes's husband is not willing to help assist patient upon discharge with her stoma care for failed laparoscopic cholecystectomy. Scenario 5 Three days after discharge, you receive a phone call from Mrs. Stukes's neighbor, who is helping take care of her. She is requesting the names and home phone number for the wound care nurse who saw Mrs. Stukes while she was an inpatient.

Scenario 1 Wash and glove Hands Full assessment Allow expression of feelings Educate patient Evaluate understanding Scenario 2 Wash and glove up Full assessment Check Ng tube placement Administer IV antiemetic medication Scenario 3 Full assessment Educate patient Evaluate understanding Notify lead nurse and doctor Consult Wound Care Scenario 4 Discuss with patient identify home health needs Notify lead nurse/doctor of new circumstances Contact Social Services for new consult Update patient on discharge changes Scenario 5 Follow HIPPA Protocol Explain HIPPA Protocol Offer resource assistance to caller Contact Wound Care directly Document Conversation

Sarah Getts Scenario 1 Ms. Getts is requesting water to drink. Her pitcher has already been filled three times this shift. Scenario 2 Three hours later, Ms. Getts is unsteady when standing by her bedside. Scenario 3 You observe Ms. Getts being assisted by another nurse who is being blatantly rude and disrespectful to her. Scenario 4 Ms. Getts is now complaining of sudden sharp, substernal chest pain, very short of breath and is profusely diaphoretic. Scenario 5 Ms. Getts is being transferred as an emergency to Critical Care. Your responsibilities are:

Scenario 1 Wash and glove hands Full assessment Monitor and evaluate fluid intake Educate patient Document results Scenario 2 Wash and glove hands Full assessment Apply fall risk bracelet Document results Scenario 3 Offer assistance Remain with patient Therapeutic Communication Notify lead nurse Document results Scenario 4 Visual assess Call rapid response Apply oxygen Establish second IV Remain with patient Scenario 5 Give verbal report Escort patient Notify family Document results

Estelle Hatcher Senario 1 Ms. Hatcher is second day post-op and has a nasogastric tube set to gravity drainage only. She presses call light with questions about who her nurse will be and her NG-tube. Senario 2 During the follow up nursing assessment, Ms. Hatcher complains about the nasogastric tube causing her pain in her nasal area. She has active bowel sounds. Senario 3 Dr. Brown gives orders to remove nasogastric tube set to gravity and to begin a clear liquid diet. Senario 4 Mrs. Hatcher appears restless, diaphoretic and calls nurse for help. Upon entering room, what order of appropriate steps do you take? Senario 5 Several hours later, Mrs. Hatcher is feeling much better. She puts on her call light and asks to see a nurse. Upon entering the room, she asks you if she will be able to drive when she gets home tomorrow.

Senario 1 Introduce Yourself/Identify Patient Full Assessment Educate Patient Evaluate Understanding Provide Comfort Senario 2 Wash/Glove Hands Inspect Pain Location Check Proper Positioning Verify Call Light/Bed Safety precautions Notify Doctor (for possible Removal) Senario 3 Educate patient of procedure Evaluate Understanding Remove NG-Tube Administer Diet Order Document Results Senario 4 Wash/Glove hands full assessment encourage incentive spirometry Verify call light/bed safety precautions Document Results Senario 5 Use therapeutic communication/active listening Educate patient Evaluate Understanding Verify call light.bed safety Document results

Viola Cumble Senario 1 Ms. Cumble states that she has not had a BM for three days. Senario 2 Ms. Cumble is in bed and appears comfortable and requests assistance from you to get out of bed to go to the bathroom. Senario 3 Vital signs are to be taken BID, and it is now time. Senario 4 Temperature is now 102.8. Senario 5 It is now third day post-op, the order is for Ms. Cumble to stand by bedside on both legs for 5 minutes, three times a day.

Senario 1 Assess for bowel sounds Administer PRN constipation medications Encourage fluids and fiber diet Evaluate understanding Review pain medication order Senario 2 Check physician orders Educate patient Offer bedpan Record intake and output Verify call light/bed safety precautions Senario 3 Obtain vital signs machine Wash and glove hands Identify patient Assess vital results Document results and findings Senario 4 Wash and glove hands Administer antipyretic medication Encourage fluids Notify doctor Document results and findings Senario 5 Notify Physical Therapy (PT) PT to educate patient Read PT report Re-assess patient Evaluate/Modify Mobility Plan

Robert Strurgess Senario 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." Senario 2 It is determined that Mr. Sturgess could achieve better pain control with a PCA pump. Senario 3 Mr. Sturgess does not have a living will or durable power of care completed. Senario 4 Mr. Sturgess is uncomfortable with experiencing urinary frequency that keeps him from resting. Senario 5 Mr. Sturgess is now declining, and family members are requesting to remain in room past normal visiting hours.

Senario 1 Wash and glove hands Full assessment Seek clarification Check PRN pain order Verify call light/bed safety precautions Senario 2 Full assessment Educate patient regarding changes to POC Place patient on PCA pump Observe closely first hour Perform pain re-assessment Senario 3 Use therapeutic communication/active listening Educate patient/family Notify doctor Contact Social Services Report and document results Senario 4 Use therapeutic communication/Active Listening Notify doctor for Foley catheter Education of Foley Cath Procedure Insert Foley catheter Document Procedure Senario 5 Allow family to remain Full assessment Provide comfort and pain measures Pain re-assessment Document results

Tom Richardson Senario 1 Day 2 admission, Thomas Richardson is complaining of severe pain and is now begging you for some relief; states pain scale 10/10. Senario 2 Mr. Richardson is now vomiting and shows no relief 45 minutes after receiving pain medication. Senario 3 Mr. Richardson is requesting assistance to ambulate to bathroom. Senario 4 Mr. Richardson is now pain free and questioning why he is plagued with recurring urinary stones. Senario 5 You are now preparing for discharge, place steps in order:

Senario 1 Wash and glove hands Vital assessment Administer pain medications Re-assess patient Document results Senario 2 Vital Assessment Notify Doctor for pain medz Administer new pain medz Re-assess patient Senario 3 Use therapeutic communication/Active Listening Obtain urinary screen Assist patient Remain with patient Document results and findings Senario 4 Use therapeutic communication/Active Listening Educate patient Evaluate understanding Contact dietary consult Document results Senario 5 Discharge instructions Evaluate understanding Escort patient to vehicle Document results Notify housekeeping