Medical Surgical

Hildegard Lowe

Educational Needs: Increased Fall Risk: Increased Health Change: Increased Neurological: Normal Pain level: Normal Psychological: Normal Acute pain: false Bleeding, risk for: false Impaired mobility, risk for: true Nausea: false Deficient knowledge: true Grieving: false Impaired gas exchange, risk for: true Ineffective breathing pattern: true Peripheral Neurovascular dysfunction, risk for: true Risk for Infection: true Scenario 1: 1Reposition head of bed to semi-fowlers 2Increase supplemental oxygen from to 2L to 4L 3Orient patient to environment and plan of care, and inform her that her daughter will be here shortly 4Initiate incentive spirometry treatment 5Retake vital signs Scenario 2: 1White Blood Cell Count (WBC): 15,600 mm³ 2Magnesium: 1.6 mg/dl 3Red Blood Cell Count (RBC): 3.59 RBC × 10⁶/µl 4Hemoglobin (Hgb): 10.9 g/dl; Hematocrit (Hct): 34.3 % 5BUN: 6 mg/dl Scenario 3: 1Stop the infusion 2Don gloves 3Inspect site 4Collect supplies 5Remove IV and document Scenario 4: 1Have the secretary ask the daughter for her name and number 2Review current hospital's HIPAA policy 3Discuss the policy on releasing information to family members with 4Ask Hildegard what information she would like to disclose to family and questions about the policy 5Document teaching to Hildegard, as well as patient's preferences 6Talk to the daughter Scenario 5: 1Don gloves and assist patient with hygiene, and instruct patient not to flush 2Assess the stool and flush 3Assist patient to bed, obtain current vital signs, and conduct a focused abdominal assessment 4Anticipate need for stool specimen collection 5Call the Physician with findings 6Place patient on enteric contact precautions

Preston Wright

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

Ann Rails

Educational Needs: Increased acuity Fall Risk: Increased acuity Health Change: Increased acuity Pain Level: Increased acuity Psychological Needs: Increased acuity

Tom Richardson

Educational Needs: Increased acuity Fall Risk: Increased acuity Health Change: Increased acuity Pain Level: Increased acuity Psychological Needs: Normal acuity Sensorium: Normal acuity Acute Pain: True Electrolyte Imbalance: False Imbalanced Nutrition: False Impaired Mobility, Risk for: True Impaired Skin Integrity, Risk for: False Impaired Urinary Elimination: True Fall, Risk for: True Sleep Deprivation: False Scenario 1: 1 - Wash and glove hands 2 - Vital assessment 3 - Administer pain medications 4 - Re-assess patient 5 - Document results Scenario 2: 1 - Vital Assessment 2 - Notify Doctor for pain meds 3 - Administer new pain meds 4 - Re-assess patient Scenario 3: 1 - Use therapeutic communication/Active Listening 2 - Obtain urinary screen 3 - Assist patient 4 - Remain with patient 5 - Document results and findings Scenario 4: 1 - Use therapeutic communication/Active Listening 2 - Educate patient 3 - Evaluate understanding 4 - Contact dietary consult 5 - Document results Scenario 5: 1 - Discharge instructions 2 - Evaluate understanding 3 - Escort patient to vehicle 4 - Document results 5 - Notify housekeeping

John Duncan

Educational Needs: Increased acuity Fall Risk: Increased acuity Health Change: Increased acuity Pain Level: Increased acuity Psychological Needs: Normal acuity Sensorium: Normal acuity Deficient Fluid Volume: True Electrolyte Imbalance, Risk for: True Excess Fluid Volume, Risk for: False Fatigue: True Nausea: False Self-Care Deficit: False Fall, Risk for: True Infection, Risk for: False Ineffective Coping: False Noncompliance: True Scenario 1: 1Assess intake and output and possible reasoning 2Construct dietary consult (plan) 3Acquire daily weight and food intake 4Evaluate outcome of dietary plan Scenario 2: 1Full assessment including both lying/standing 2Check input/output for possible dehydration 3Teach patient about safety when getting out of bed 4Document findings Scenario 3: 1Wash and glove hands 2Provide emesis basin/cloth 3Vital sign assessment 4Administer antiemetic medication 5Evaluate medication effectiveness Scenario 4: 1Vital sign assessment 2Assessment of bowel movement 3Administer protocol antidiarrheal medication 4Document results/findings 5Include patient condition change in shift report Scenario 5: 1Inform and educate spouse of dietary orders 2Evaluate/modify plan of care 3Assess food consumption and intake and output 4Document findings/results

Jody Rush

Educational Needs: Increased acuity Fall Risk: Increased acuity Health change: Increased acuity Neurological: Normal acuity Pain level: Increased acuity Psychological: Needs Normal acuity Acute Pain: True Bleeding risk, for: True Impaired mobility, risk for: True Nausea: True Deficient knowledge: True Grieving: False Peripheral Neurovascular dysfunction: False Scenario 1: 1Wash hands and provide patient privacy 2Complete full assessment, to include capillary refill and pedal pulses 3Medicate as needed for pain 4Encourage positioning, turning, coughing, and deep breathing post-operatively. Initiate incentive spirometry, and then hourly there after 5Orient friend in room to provide assistance with incentive spirometry to patient hourly Scenario 2: 1Complete Neuro assessment 2Educate Jody's parents to injury and surgical repair 3Offer full AM bath, and ask parents if they would like to remain in the room or step out 4Log-roll patient to complete full assessment of patients back, and to complete bath 5Ensure Foley is draining, and the IV is still patent Scenario 3: 1Inform patient and family that new orders have been given to rule out further complications 2Draw stat D-dimer blood test 3Obtain additional support to transfer patient to Radiology 4Ask parents to remain in the room 5Accompany patient and transfer patient to Radiology Scenario 4: 1Start O2 100% non-rebreather mask 2Provide SBAR to the RRT upon arrival 3Page Surgeon stat to radiology 4Prepare for Heparin administration 5Assist RRT as needed and document Scenario 5: 1Assist and support the continuous CPR during transport to the ICU 2Alert ICU of impending emergent arrival, and stat ECMO 3Following patient arrival to ICU, inform family of what has happened 4Provide emotional support; remain with patients family, offer to call family or Chaplain, and other way you can be of assistance 5Ask Charge nurse for assistance with other patients while you remain with the family, as the patient's condition is unknown

Mary Barkley

Educational Needs: Increased acuity Fall Risk: Normal acuity Health Change: Increased acuity Neurological: Normal acuity Pain Level: Increased acuity Psychological Needs: Increased acuity Acute Pain: True Deficient Knowledge: True Grieving: True Impaired Comfort: True Infection: True Scenario 1: 1Have patient put on a mask 2Wash hands and don PPE 3Use therapeutic communication to comfort patient 4Guide her back to her room while teaching her that her isolation is to protect others including her family. 5Set her up with a video chat with her family. Scenario 2: 1Initiate O2 at 2L nasal-cannula. 2Alert 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. 3Have an aide sit with Ms. Barkley while you obtain the IV supplies, and notify the Healthcare Provider of her declining condition. 4Wash hands and dawn PPE and restart IV and secure with gauze wrap. 5Secure sitter to stay with Ms. Barkley after the insertion of the new IV. Scenario 3: 1Contact RT for a stat CPAP trial. 2Obtain telemetry set-up and take to patients room. 3Ask PCT to secure mask better, and inform her that there is no replacement for her. 4Don PPE and have PCT assist with connecting the patient to Telemetry. 5Assist RT to initiate CPAP trial. Scenario 4: 1Call rapid response, RRT. 2Continue to assist RT in ventilation. 3Give SBAR to RRT upon arrival. 4Call for crash-cart for possible intubation. 5Ensure documentation of time and events of RRT. Scenario 5: 1Encourage Healthcare Provider to consider intubation in the absence of signed DNR. 2Offer to contact family for Healthcare Provider. 3Contact Assisted Living facility (ALF) to see if patient has an Advanced Directive in place declining. 4Notify the Healthcare Provider of absence of Advanced Directive and families request to intubate. 5Assist with intubation, and logistics of managing the critical patient on the floor.

Linda Pittmon

Educational Needs: Increased acuity Fall Risk: Increased acuity Health Change: Increased acuity Neurological: Increased acuity Pain Level: Normal acuity Psychological Needs: Normal acuity Anxiety: False Disturbed body image: True Disturbed sleep pattern: False Impaired Memory: False Ineffective health maintenance: True Risk for malnutrition: True Impaired tissue integrity: True Isolation precautions: False Risk for physical injury: True Risk for urinary retention: False Self-care deficit: True Scenario 1: 1Wash hands and don gloves 2Obtain blood for lab testing and blood culture #1 3Obtain blood for lab testing and blood culture #2 4Initiate IV fluids to peripheral site 5Administer levofloxacin as ordered Scenario 2: 1Assess VS and perform a neurological focused assessment 2Place the syringe in a biohazard bag and place a pt id label on bag 3Ask the pt if she knows where the syringe came from and what was in the syringe 4Notify the charge nurse and house supervisor of the syringe found in bed 5Notify the physcian of assessment findings and await further orders Scenario 3: 1Assess VS and perform head to toe assessment 2Therapeutic communication w/ pt 3Call HCP for change in health status and receive orders for anxiety medication 4Prescribed medication for anxiety must be administered 5Assess for therapeutic response to medications Scenario 4: 1Ask Mrs. Pittman if she remembers the conversation w/ the physician and if she has any further questions that need to be addressed. 2Perform pre op checklist 3Ensure signed consents are on the chart 4Ensure type and cross match for blood products is complete and results are in electronic medical record 5Have IV abx amiable to administer when surgery calls for the pt to be transferred to pre op area Scenario 5: 1Pre-medicate for pain w/ prescribed medication 2Don clean gloves to remove old dressing 3Monitor neurovascular status assessing skin color, temp, sensation and pulses above amputation. 4Don 2nd set of clean gloves to provide stump care. The wound has been sutured and is not and open wound/stump. 5Elevate stump and reward w/ a dry clean dressing.

Jose Martinez

Educational Needs: Increased acuity Fall Risk: Increased acuity Health Change: Increased acuity Neurological: Normal acuity Pain Level: Normal acuity Psychological Needs: Normal acuity Acute Pain: True Altered body image: False Anxiety: True Disturbed thought process: False Impaired gas exchange: true Impaired tissue perfusion: True Ineffective health maintenance: True Powerlessness: True Drug therapy: True Risk for social isolation: False Scenario 1: 1Assess airway, breathing, circulation. 2Administer oxygen therapy to make sure oxygen saturation is greater than 90% 3Ensure continuous EKG monitoring. 4Provide Morphine Sulfate IVP as prescribed 5Reassess patient's vital signs and pain level. Scenario 2 1Assess for the abrupt cessation of pain 2Initiate IV Heparin 3Give ASA 4Observe for bleeding. 5Monitor aPTT Scenario 3 1Provide emotional support 2Assess Mr. Martinez's willingness to learn 3Provide introductory information on prescribed antithrombotic medication 4Report Mr. Martinez's emotional distress to Case Management 5Document all findings. Scenario 4 1Troponin 1.0 mg/mL. 2CPK: 360 mcg/mL 3CK-MB6.8 4Serum Potassium 4.2 mEq/L 5Serum Sodium 142 mEq/L Scenario 5 1Clarify with Mrs. Martinez that she is asking if it is okay to resume sexual relations with her husband upon discharge. 2Promote open communication between Mr. and Mrs. Martinez 3Explain to Mr. and Mrs. Martinez the disease process following myocardial infarction 4Discuss physical limitations following myocardial infarction 5Provide information to Mr. and Mrs. Martinez regarding support groups.

Keaton Henderson

Educational needs: increased Fall risk: increased Health change: increased Pain level: Normal Psychological: normal Neurological: normal Acute pain: True Bleeding, risk for: True Impaired comfort: True Nausea: False Fall risk: True Grieving: False PND: False Scenario 1: 1 - Introduce yourself to pt and inquire about patient's pain and comfort 2 - Take his V/S 3 - Auscultate lung sounds and inspect wound site 4 - inspect pleurovac 5 - Mark the drainage level of the pleurovac Scenario 2: 1 - Assess his vital signs 2 - Assess patient's chest tube insertion site 3 - Check his pleurovac 4 - Administer pain medication 5 - Encourage patient to use IS Scenario 3: 1 - Assess for mediastrinal shift or tracheal deviation 2 - Administer 100% oxygen 3 - Auscultate lung sounds 4 - Assess pleurovac patency 5 - Call for RR Scenario 4: 1 - Explain to the pt the plan of care, and that the procedure may be painful. 2 - Obtain 16 gauge angiocath and prep the second midline intercostal space on the right side 3 - Set up sterile thoracic tray for chest tube insertion 4 - Obtain and fill a new pleurovac and Vaseline-gauze dressing 5 - Assist w/ new chest tube insertion Scenario 5: 1 - Assess V/S 2 - Auscultate all lung fields 3 - Complete stat portable chest xr 4 - Inspect insertion site and ensure no leakage of blod/air 5 - Ensure chest tube is closed to water seal

Janene Whitmore

Educational: Increased Fall Risk: Increased Health Change: Increased Pain Level: Increased Psychological: Increased Neurological: Normal Acute Pain: true Bleeding: true Impaired comfort: true Nausea: false Deficient Knowledge: True Infection, Risk for: True Peripheral Neurovascular Dysfunction: false Scenario 1: 1Explain to the patient that the hospital does not yet have a formal bloodless treatment program, but every effort will be made to meet her request 2Medicate patient for abdominal discomfort 3Initiate IV and draw labs 4Put an arm band on patient that signifies refusal of blood 5Ask patient if she has contacted her hospital liaison representative Scenario 2: 1Explain to Ms. Whitmore that more labs are necessary to reassess patient's hemodynamic status 2Inform patient that you are drawing labs for CBC, electrolyte panel, platelets function, and a type and screen 3Explain to patient that a T&S is required should she decide to change her mind and want blood 4Reassure patient that you are minimizing blood loss from frequent phlebotomy by using pediatric vials 5Ask Ms. Whitmore if she has any further questions Scenario 3: 1Contact Charge nurse/nursing supervisor 2Contact hospital liaison representative 3Inform patient that you are advocating for her, and exploring treatment provider options 4Inform admitting Physician/OBGYN 5Document Scenario 4: 1Ask patient if she is comfortable taking Epoetin and if she would like to discuss this treatment with her hospital liaison representative 2Administer Epoetin IV 3Patient teaching about Iron administration 4Administer diluted Iron IV in a 100mL of NS over 15 minutes 5Reassess patient for reactions in 15 minutes Scenario 5: 1Remind surgeon and staff that this is not an appropriate place to be discussing this patient 2Notify HIPAA compliance officer of what you witnessed 3Notify Charge nurse/ nursing supervisor 4Suggest to the nursing supervisor the need for nurse education of management of JW patients with bloodless treatment 5Introduce the hospital liaison representative for nursing education

Don Johnson

Educational: Increased Fall Risk: Increased Health Change: Increased Pain Level: Increased Psychological: Increased Neurological: Normal Acute pain: True Altered body Image: true Audiology changes, risk for: True Bleeding: False Fluid and electrolyte imbalance, risk for: True PTSD, risk for: True Infection, risk for: True Scenario 1: 1 Complete full assessment 2 Insert foley catheter 3 Initiate IV at 450mL per hour 4 Apply Silvadene and sterile gauze 5 Contact HCP for central line Scenario 2: 1 Reassess lung sounds 2 Empty foley bag and measure urinary output 3 Administer pain medication 4 Notify HCP of worsening condition 5 Document new burn findings Scenario 3: 1Elevate the head of the bed 2Assess the patient's sputum 3Reassure the patient that a Plastic Surgeon will review his burns once he is healed 4Assure the patient that the young lady is being treated, but you cannot give any details on the patient's condition 5Contact respiratory therapy to see the patient ASAP Scenario 4: 1Obtain doppler pulse 2Adjust the rate of IV infusion to 225 mL/hr 3Ask for an available tech to assist with patient care 4Change dressing and bed linen's 5Determine if the patient has been included in trauma debriefing Scenario 5: 1Obtain bear hugger from the OR 2Explain to the patient that he must remain NPO 3Notify nursing supervisor of the room temperature problem 4Contact nutritionist to evaluate caloric needs and nutritional intervention 5Allow the visitors to enter while maintaining contact isolation

Robert Sturgess

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

Wight Goodman

Educational: Increased Fall Risk: Increased Health Change: Increased Pain Level: Increased Psychological: Normal Neurological: Normal Acute Pain: True Bleeding, risk for: True Impaired Comfort: True Deficient Knowledge: True Infection, risk For: True Scenario 1: 1Wash hands and assess 2Complete neuro assessment 3Halo test 4Pre-op education 5Ask surgeon to discuss with pt the potential facial scarring Scenario 2: 1Complete neuro assessment 2Educate pt of plan of care 3Evaluate pt understanding of care 4Administer IV abx 5have pt sign additional surgical consent Scenario 3: 1Complete neuro assessment 2Educate pt and family of necessity for q2hr neuro checks 3Inform HP that pt is medically indigent 4Contact social services 5Extensive discharge planning and education Scenario 4: 1Repeat neuro assessment and contrast your latest findings. 2Reemphasize to patient that he cannot blow his nose. 3Approach resident again, and explain that you feel his condition is worsening. 4Contact nursing supervisor of disagreement of patients readiness for discharge. 5Document Scenario 5: 1Take VS and position patient 30 degrees upright 2Restart patients IV 3Obtain surgical consent. 4Assure pt that surgery is necessary to preserve his sight. 5Remain with pt

Glenn Massey

Educational: Increased Fall Risk: Increased Health Change: Increased Pain Level: Increased Psychological: Normal Neurological: Normal Acute pain: True Bleeding, risk for: false Impaired mobility, risk for: true Nausea, risk for: true Deficient knowledge: true Grieving: false Peripheral Neurovascular dysfunction: false Scenario 1: 1Ensure room was cleaned thoroughly 2Disinfect call light, bed rails, and overbed table 3Clean and obtain IV pole 4Obtain burn sheets from CS and make bed 5Notify infection control nurse, and put signage on door for wound isolation Scenario 2: 1Obtain vital signs using thigh cuff 2Initial assessment (head to toe) 3Administer pain medication, as indicated 4Educate patient regarding plan of care 5Check patient's charts for last dressing change Scenario 3: 1Hand hygiene 2Set-up supplies on clean surface 3Apply clean gloves 4Gently peel off old dressing and don sterile gloves 5Clean wound site in circular motions starting at insertion site, moving outwar 6Apply new dressing with today's date and initials Scenario 4: 1Notify HCP of critical lab values 2Inform patient of new plan of care as a result of critical lab values 3Initiate cardiac telemetry as ordered 4Give 1L NS per HCP's order 5Empty foley bag and record output; begin hourly output Scenario 5: 1Explore why patient is anxious to return to work 2Educate patient on typical treatment and course of therapy timelines 3Evaluate patient's understanding 4Contact social services for occupational injury benefits 5Involve family in plan of care, per patient's request

Kenny Barrett

Educational: Increased Fall Risk: Increased Health Change: Increased Pain Level: Increased Psychological: Normal Sensorium: Increased Acute Pain: True Bleeding risk: false Deficient knowledge: true Fall risk: true Peripheral neurovascular dysfunction: false

Ramona Stukes

Educational: Increased Fall Risk: Increased Health Change: Increased Pain Level: Increased Psychological: Normal Sensorium: Normal Bleeding, Risk for: true Constipation: false Deficient Fluid Volume, Risk for: True Dysfunctional Gastrointestinal Motility: false Imbalanced Fluid Volume: false Impaired Mobility: true Anxiety: false Fall, Risk for: true Ineffective Self-Health Management: false Infection, Risk for: true Scenario 1: 1Wash and glove hands 2Full assessment 3Allow expression of feelings 4Educate patient 5Evaluate understanding Scenario 2: 1Wash and glove up 2Full assessment 3Check Ng tube placement 4Administer IV antiemetic medication Scenario 3: 1Full assessment 2Educate patient 3Evaluate understanding 4Notify lead nurse and doctor 5Consult Wound Care Scenario 4: 1Discuss with patient identify home health needs 2Notify lead nurse/doctor of new circumstances 3Contact Social Services for new consult 4Update patient on discharge changes Scenario 5: 1Follow HIPPA Protocol 2Explain HIPPA Protocol 3Offer resource assistance to caller 4Contact Wound Care directly 5Document Conversation

Lithia Monson

Educational: Increased Fall Risk: Increased Health Change: Increased Pain Level: Normal Psychological: Increased Sensorium: Increased Bleeding, Risk for: True Decreased Cardiac/perfusion: false Imbalanced Nutrition: true Nausea: false Self-Care Deficit: true Shock, Risk for: false Acute Confusion: true Fall, risk for: true Peripheral Neurovascular Dysfunction: false Sleep deprivation: false Compromised Family Coping: false Failure to Thrive: true

Kathy Gestalt

Educational: Increased Fall Risk: Increased Health Change: Increased Pain Level: Normal Psychological: Increased Sensorium: Normal Acute Pain: True Chronic Pain: False Impaired Mobility: True Impaired Skin Integrity, Risk for: true Ineffective Peripheral Tissue Perfusion: false Self-Care Deficit: false 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 Decisional Conflict: true Deficient Diversional Activity: false Disturbed Body: true Hopelessness: false

Estelle Hatcher

Educational: Increased Fall Risk: Increased Health Change: Increased Pain Level: Normal Psychological: Normal Sensorium: Normal

Ruth Cummings

Educational: Increased Fall Risk: Increased Health Change: Increased Pain: Increased Psychological: Increased Neurological: Normal Acute Pain: True Bleeding, risk for: False Deficient knowledge: True Impaired mobility, risk for: True Nausea: True Grieving: False PND: False Scenario 1: 1Orient patient to the room and complete head-to-toe assessment 2Educate patient need for NG tube 3Administer a rectal suppository for nausea and pain. 4Assess IV for patency. 5Insert NG tube Scenario 2: 1Describe to patient what incentive spirometry is and its purpose 2Explain how surgery causes shallow respirations 3Practice using IS for baseline preoperatively 4Reinforce need for hourly use 5Evaluate patient understanding and document teaching and baseline tidal volume Scenario 3: 1Ensure signed surgical consent is on the chart 2Take vital signs 3Ask patient to verify procedure 4Check for IV patency 5Disconnect NG tube and place on portable suction Scenario 4: 1Receive handoff report from PACU nurse 2Assess/inspect surgical sites 3Take vital signs and assess for pain 4Elevate head of bed 5Give patient the call light, and explain that she is not to get out of bed without assistance Scenario 5: 1Assist patient back to the bed 2Ensure side rails are down, and the patient uses the call bell 3Notify charge nurse 4Notify HCP 5Complete incidence report

Kate Bradley

Educational: Increased Fall Risk: Increased Health Change: Increased Pain: Increased Psychological: Increased Neurological: Increased Acute Pain: True Bleeding, risk for: True Impaired Comfort: True Impaired mobility: True Deficient knowledge: True Fall, risk for: True Grieving: False Infection, risk for: True Scenario 1: 1Complete full assessment 2Secure help for bed bath 3Medicate for pain 4Contact Nursing Supervisor 5Complete bed bath Scenario 2: 1Reassess vital signs 2Report discrepancy in vital signs to Charge nurse 3Notify HCP that patient is now febrile, 101.5 F, 38.6 C 4Contact IV team to restart the IV 5Document all finding, and attempt to contact family again for surgical consent Scenario 3: 1Explain to the surgeon that she was told that patient was told to go to pre-op in the afternoon 2Check on labs to determine if they were drawn 3Contact Charge nurse and nursing supervisor 4Meet with daughter and explain events; determine her competency to sign surgery consent 5Assess patient and make ready to transport to pre-op Scenario 4: 1Provide therapeutic communication 2Assess her last medication for pain 3Assist the IV team to restart the IV 4Explain to the daughter what is going on, and allow her to remain with her mother 5Contact social services while daughter is present Scenario 5: 1Witness daughter signing consent 2Call report to pre-op holding 388 y/o female, fractured right hip, confused. Daughter has signed the surgical consent. 4Former nursing home patient, and injured 2 days ago at Shady-Rest 5Patient has a Foley catheter that is draining cloudy urine, and is febrile. Her vital signs are: T:101.5 F, 38.6 C, P: 92, BP: 104/52, R: 18, PaO2 92% 6Have the daughter stay with the patient as she is more compliant with her present. Remind PACU staff to position patient to stay off the decubitus. Inform the staff that the daughter has been belligerent, and smells of alcohol.

Trey Johnson

Educational: Increased Fall Risk: Normal Health Change: Increased Pain: Increased Psychological: Increased Sensorium: Normal Acute Pain: True Bleeding, risk for: False Impaired mobility, risk for: False Nausea: True Deficient knowledge: True Grieving: False Peripheral Neurovascular dysfunction: False Scenario 1: 1Vital signs and head to toe assessment 2Collect stool sample and obtain HCP order 3Initiate IV 4Initiate I&O 5Teach patient to record all bowel movements descriptively Scenario 2: 1Place patient on respiratory isolation with contact precautions 2Re-locate patient to a negative pressure room 3Contact HCP for orders for anxiety/adnominal pain 4Provide PRN anti-diarrhea medication 5Continue strict I&O with daily weights Scenario 3: 1Notify infection control nurse 2Patient education for new treatment plan 3Initiate medication (INH/PAS, duration?) 4Continue medicating for abdominal discomfort and frequent diarrhea 5Discuss coping strategies for patient's time in isolation Scenario 4: 1Allow patient to express his feelings 2Educate patient on his prognosis 3Evaluate patient understanding 4Notify HCP for further Psychological evaluation 5Document Scenario 5: 1Educate patient of protocols for necessary medications and side effects 2Educate patient of transmission of his disease 3Evaluate potential barriers to patient's compliance 4Educate patient of need for repeat 30-day lab review 5Evaluate patient's understanding

Dana Fitzgerald

Educational: Increased Fall Risk: Normal Health Change: Increased Pain: Increased Psychological: Normal Neurological: Normal Acute Pain: False Nausea: False Deficient Knowledge: True Disturbed Sensory Perception: False Grieving, risk for: True Infection, risk for: True Scenario 1: 1Sit with the patient and provide emotional support by using open-ended questions. 2Reinforce provider teaching that fibroid uterine masses are rarely cancerous. 3Assess family support system 4Reassure the patient that she can make a full recovery from surgery, and it should not interfere with the adoption process. 5Ask the patient if they would like to speak with a clinical counselor or chaplain Scenario 2: 1Head to toe assessment to include surgical site 2Inspect catheter to ensure it is not obstructed/kinked 3Teach patient that the catheter makes it feel like she needs to void 4Instruct patient not to get up without assistance. Administer pain medication and ensure side rails are up, the bed is in the lowest position, and the call light is within reach. 5Ask the charge nurse for help locating a PCA from another floor. Then, obtain an order for Colace and inform the provider that you are trying to find a PCA pump. Scenario 3: 1Teach the patient that the pain medication works best if she ambulates and uses the incentive spirometer after the pain medication is administered. 2Explain to the patient the importance of the incentive spirometer q15 minutes. Instruct the patient and husband that she does not ambulate without assistance and to call for help. 3Administer pain medication and have the patient demonstrate incentive spirometer technique. Teach patient how to use a pillow as an abdominal splint while coughing and deep breathing 4Tell the patient that she must drink plenty of fluid 5Have the patient ambulate a short distance with your assistance Scenario 4: 1Inspect the patient's abdomen 2Auscultate starting at the right lower quadrant beginning at the right lower and continuing to all others 3Percuss and palpate all quadrants as tolerated. 4Contact provider before administering additional pain medication. 5Tell the husband and patient you have notified the HCP and are doing further assessments Scenario 5: 1Inform the patient that the pain medication worsens her constipation, and the fleets' enema has been ordered. 2Provide patient privacy and lay the patient on their left lateral side. 3Lubricate the tip of the enema tip or catheter and insert it into the rectum gently. 4Squeeze the content into the rectum while telling her to take slow deep breaths 5Have the patient lay on their side and retain an enema if they can tolerate it. Then, assist the patient to commode or onto a bedpan.

Dotty Hamilton

Educational: Increased Fall Risk: Normal Health Change: Normal Pain Level: Normal Psychological: Increased Sensorium: Normal Bleeding, risk for: True Impaired comfort, risk for: True Nausea: False Deficient Knowledge: True Infection, Risk for: true Peripheral Neurovascular disfunction: False Scenario 1: 1Contact Surgeon 2Complete pre-operative assessment 3Ensure surgical consents have been signed and witnessed 4Check to see if patients type and cross match as ordered has been completed. 5Patient teaching, post-op care to include incentive spirometry practice. Scenario 2: 1Wash hands. 2Complete full assessment, to include IV, patency, foley catheter, and NG tube placement. 3Check wound sites for drainage 4Use therapeutic communication, and offer ice chips, mouth care 5Encourage first incentive spirometry Scenario 3: 1Reassure and communicate to patient and husband that she has notified the Doctor 2Check blood glucose finger stick and administer sliding scale insulin 3Administer antibiotics 4Encourage aggressive incentive spirometry 5Start the PCA pump scenario 4: 1Reassure patient of plan of care 2Complete full patient assessment, to include foley catheter, operative wound sites, and NG tube 3Assess whether or not you can start IV, if not call anesthesia 4Obtain labs 5Notify HCP and nursing supervisor of patients deteriorating condition Scenario 5: 1Complete full assessment 2Place patient on telemetry, and monitor BP q15 minutes 3Check foley catheter hourly for output 4Assist Anesthesia with insertion of central line 5Explain to patient and family why central line is necessary. Scenario 6: 1Have the family step out of the room. Bathe the patient, and make her as presentable as possible for the next family visit. 2Bring the family in, if they desire, to spend the last few moments before the funeral home arrives 3Offer to the family to contact any clergy member or other family members 4Contact funeral home 5Ask nursing manager to help debrief and document concerns with what possibly went wrong with patients care.

Hannah Knox

Educational: Increased Fall risk: Increased Health Change: Increased Neurological: Normal Pain: Increased Psychological: Increased Bleeding, Risk For: False Chronic Pain: True Impaired Comfort: True Deficient Knowledge: True Fear of death: True Gas exchange, risk for: True Infection, Risk For: True Scenario 1: 1 - Full assessment, focused on mental status 2 - Contact IV team 3 - Contact HCP to see if they can apply a PureWick, female external catheter 4 - Set-up PCAA 5 - Contact social services Scenario 2: 1 - Administer antibiotics and start Morphine PCA with a basal rate of 4mg/hour, and demonstrate to patient how to administer 2 - Contact hospice/social work for history of pain medications for dosage and effectiveness 3 - Place patient on continuous pulse ox 4 - Reassess effectiveness of PCA 5 - Document Scenario 3: 1 - Reassess vital signs and elevate head of bed 2 - Continue to provide palliative care 3 - Seek clarification about advanced directives and DNR status 4 - Call respiratory therapy and assist with treatments 5 - Provide emotional support for patient and family and ask if they would like you to contact a hospital chaplain Scenario 4: 1 - Full assessment 2 - Place patient on 100% non-rebreather/10L ensuring the reservoir bag is fully expanded 3 - Review PCA pump history 4 - DNR armband and tag on patient's bed/wall 5 - Discuss with HCP concerns of morphine dose and respiratory status Scenario 5: 1 - Contact HCP 2 - Contact chaplain 3 - Take patient's family to a quiet room 4 - Prepare Ms. Knox body for final viewing 5 - Notify social services that boyfriend is present

Ronald Burgundy

Educational: Increased Fall risk: Increased Health Change: Increased Pain: Increased Psychological: Increased Sensorium: Normal Acute Pain: true Bleeding: true Impaired comfort: true Nausea: false Deficient knowledge: true Fall, risk for: true Grieving: false Scenario 1: 1Explain 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 2Ensure there is a full O2 tank on the gurney, place patient on Nasal Cannula 3Start an IV 4Medicate for pain 5Advise patient not to get up and walk on his own Scenario 2: 1Explain to Mr. Burgundy that space in the ED is allocated based off of patient need 2Inform Mr. Burgundy that he cannot report from the ED, as patient privacy is strictly protected by HIPPA 3Ask Mr. Burgundy to lower his tone as it can be disturbing to other patients 4Reassure patient that he will be moved to a private room as soon as possible 5Reassess patient's physical status prior to leaving him in the hallway Scenario 3: 1Assess patient's ABC (airway, breathing, circulation) 2Take initial vital signs (room air Pulse Ox) 3Place patient on O2 Nasal Canula 4Start IV 5Set-up for stat portable chest x-ray Scenario 4: 1Explain procedure to the patient 2Place patient on 100% O2 3Ensure there is suction in the room, and check 4Obtain chest tube tray and set-up pleurovac 5Reassess patients' vital signs, and place on q5 minutes continuous monitoring Scenario 5: 1Instruct Mr. Burgundy and his cameraman to stop immediately 2Notify charge nurse 3Call security for assistance and compliance officer 4Transport Mr. Burgundy to his room 5Complete incident report

Calvin Umbyuma

Educational: Increased Fall: Normal Health change: Increased Pain: Increased Psychological: Normal Neurological: Normal Acute pain: True Bleeding, risk for: False Impaired mobility, risk for: False Nausea: False Deficient knowledge: True Grieving: False Peripheral Neurovascular dysfunction: False Scenario 1: 1Place on respiratory isolation 2Ask Mr. U about the traditional methods he is currently receiving 3Inform the provider that a sputum culture is needed and to check sputum for acid-fast bacilli 4Start IV 5Obtain blood cultures x2 Scenario 2: 1Wash hands, don PPE 2Explain to the visitor that a mask must be worn, and they need to wash their hands 3Respiratory assessment and assess vital signs 4Explain to Mr. U why he can't take his other medication while admitted to the hospital 5Ask Mr. U for his medications and supplements 6Place signage on door and above bed reminder to wear a mask and wash hands Scenario 3: 1Ask patient what he knows about Tuberculosis 2Ask patient what his mother's symptoms are 3Educate patient to the signs/symptoms of Tuberculosis 4Evaluate effectiveness of patient education 5Report findings to the HCP, notify infection control and social services Scenario 4: 1Patient teaching about diagnostic testing (Bronchoscopy) 2Western blot and Elisa test 3Contact Respiratory therapy to obtain ABG's 4Chest x-ray 5Bronchoscopy Scenario 5: 1Elevate head of bed 2Initiate O2 at 4L nasal canula 3Reevaluate amount of blood lost by coughing 4Contact HCP and nursing supervisor 5Contact respitory therapy for potential intubation

Arthur Thomason

Educational: Increased Health Change: Increased LOC: Increased Pain Level: Increased Psychological: Increased Safety: Increased Impaired Comfort: True Impaired Gas Exchange: True Ineffective airway clearance: True Shock, risk for: True Chronic confusion: False Anxiety/fear: True Failure to thrive, risk for: True Scenario 1: 1 Assess: Assessment is the first step of nursing process. 2 Replace oxygen nasal cannula that had become disconnected: ABC's are priority in patient care 3 Use therapeutic communication: Active listening allows patient to express herself and is first step to understanding patient condition. 4 Notify doctor and charge nurse: Communicate change in condition. Scenario 2: 1Remind physician to wash his hands before examining the patient 2Explain to physician what interventions you have recently initiated 3Assist physician in physical exam of patient 4Obtain recent chest X-ray reports and recent ABG's for physician to review 5Reassure patient and help explain any new orders from physician to patient Scenario 3: 1Tap patient and ask, "Are you okay?" 2Elevate head of bed 3Call Rapid Response team 4Start secondary large bore IV line 5Remain with patient and reassure Scenario 4: 1Provide verbal report to team members who respond to rapid response 2Emergency intubation and assisted breathing is provided for Mr. Thomason 3Assume role in response team of documenter 4Obtain patient record and follow patient as he is transferred to ICU 5Provide information for MD to call family at home and explain what has just happened Scenario 5: 1You explain that his condition has worsened and now he has been taken to ICU. 2You explain that he is receiving a higher level of care and was he was sedated before leaving the floor to make him more comfortable. 3You have them remain with you, seated in comfortable place, while you call ICU and attempt to locate physician for them. 4You escort them with you to the ICU. 5You call his doctor to inform him the family has arrived

Richard Dominec

Educational: Increased Health Change: Increased LOC: Normal Pain Level: Increased Safety: Increased Acute Pain: true Bleeding: false Chronic Pain: false Constipation: false Nutrition: true Risk for Infection: true Risk for Knowledge Deficit: true Skin integrity at risk: true Compromised Family Coping: false Fear/Anxiety: true Scenario 1: 1Perform full assessment and provide anti-nausea medicine. 2Provide comfort in pre-surgical room Mr. Dominec. 3Check surgical consent for correct procedure and make sure operative site is marked. 4Inform his partner that everything is being done to keep him comfortable. Scenario 2: 1Educate about recovery from appendectomy and care to wound. 2Discuss his understanding about the plan of care. 3Discuss follow up with his doctor. 4Offer assistance in providing more information about treatment options for newly dx AIDS pts. 5Determine from medical record if partner is aware of his recent AIDS dx. Scenario 3: 1You discuss this cough w/ Mr. Dominec to determine how long he has had it. 2Notify Dr of change in condition in particular; unproductive cough and low-grade fever. 3Explain to Mr. Dominec your concern for this opportunistic infection and usual tx. 4Explain that he will probably not be going home at least until his Dr. sees him 5Notify charge nurse that d/c will probably not occur today. Scenario 4: 1Inform pt about the progression and risk a PCP infection has for a pt w/ AIDS. 2Obtain and provide the ID MD contact information for him. 3Encourage Mr. Dominec to discuss w/ his partner his best tx options. 4Take VS before leaving the hospital again 5Document and provide copy for Mr. Dominec to share w/ his follow up appointment tomorrow. Scenario 5: 1This information is HIPAA protected and you cannot share anything w/ them. 2Remind staff that Universal Precautions are practiced at this hospital for all pts regardless of known ID's. 3Leave the break room and not continue in conversation. 4Report this activity immediately to the hospital privacy officer. 5report to charge nurse/head nurse the need for staff education.

Nathaniel Gonzalez

Educational: Increased Fall Risk: Normal Health Change: Increased Pain Level: Increased Psychological Needs: Normal Neurological Status: Increased acuity

Mark Robinson

Fall: Increased Educational: Increased Health Change: Increased Neurological: Normal Pain: Increased Psychological: Normal Bleeding, risk for: True Impaired comfort: True Deficient Knowledge: True ETOH withdrawal, risk for: True Grieving: False Infection, Risk for: False Peripheral Neurovascular Dysfunction: False Scenario 1: 1Educate patient on immediate plan of care in need for T&C and large bore IV 2Draw labs, to include a T&C and repeat stat hemoglobin and hematocrit 3Initiate large bore IV, 18 gauge minimal 4Advise patient not to get out of bed without assistance 5Initiate intake/output Scenario 2: 1Stop the patient from eating more of the food until they can verify with the HCP 2Explain to the wife that he cannot have any food brought in at this time 3Reassess patient for any bleeding 4Call GI provider to explain what happened, and verify diet and NPO status 5Explain to patient and wife the potential procedures Scenario 3: 1Identify the client according to facility/agency policy prior to administration of red blood cells/ blood products (e.g., prescription for administration, correct type, correct client, cross matching complete, consent obtained) 2Check the client for appropriate venous access for red blood cell/blood product administration (e.g., correct gauge needle, integrity of access site) 3Document necessary information on the administration of red blood cells/blood products 4Check vital signs then slowly begin administration through Y-tubing with normal saline 5Recheck VS q 5 min for 15 min then q 15 min for 1 hr. Scenario 4: 1Repeat H&H 2Administer ordered medications ASAP 3Explain to the patient that a sore throat is normal after this type of procedure, but to notify you immediately if there is any blood tinged sputum 4Verify with blood bank that 4 units ordered are on hand 5Verify soft, low sodium diet with HCP Scenario 5: 1Stop the platelets 2Reassess vital signs and obtain UA 3Notify HCP 4Call charge nurse/nursing supervisor 5Initiate incident report after patient has been stabilized

Sarah Kathryn Horton

educational needs - increased fall risk - increased health change - increased pain level - increased psychological needs - increased sensorium - normal acute pain: True anxiety: True Body image disturbances: False disturbed personal identity: True Fatigue: False impaired physical mobility: True impaired skin integrity: True Risk for decreased oxygenation: False risk for post trauma syndrome: True alteration of protective mechanisms: True scenario 1: 1wash hands prior to entering the room 2assess respiratory status 3do not disturb the patient 4reduce stimuli in patient room 5document all findings scenario 2: 1wash hands prior to entering the room 2assess Ms. Horton's orientation 3medicate patient 4attempt deescalation strategies 5document all findings scenario 3: 1gather supplies needed for dressing change 2wash hands upon entering the room 3explain procedure to Ms. Horton 4provide Morphine Sulfate 4 mg IV 5perform dressing change scenario 4: 1educate Ms. Horton that paroxetine is to be taken as ordered 2reinforce past coping mechanisms 3educate family regarding active listening and open communication 4educate family regarding intervention and support for Ms. Horton 5document all interactions scenario 5: 1assess Ms. Horton's orientation status 2use therapeutic communication to reorient and provide reassurance 3assist Ms. Horton back into the wheelchair 4escort patient to ER for a physical and psychological evaluation 5provide report to ER nurse