Swift River 2

JOSE MARTINEZ REPORT / ASSIGN ACCUITY Jose Martinez, Jose Martinez, 43- year old male experiencing chest pain while watching a state rival football game earlier in the evening. Chest pain became progressively worse, so he called for an ambulance to bring him to the Emergency Department. Once the ambulance arrived, he reported his pain as 10/10. The 12-lead EKG showed ST elevation. Vital signs were HR 160, BP 145/102, Respirations 23, and Pulse Ox 89%. He was given nitroglycerin during transport to the hospital with little relief. He complained of feeling "light- headed". He has been admitted to the unit, and the pain has subsided. He does have a 10-year history of hypertension. He was transferred here to the cardiac stepdown unit from the ER, because no beds were open in cardiac ICU. Ambulance report: Nitroglycerin SL x 3, 12-lead EKG, Blood drawn for cardiac enzymes, Peripheral IV started to left forearm. SCENARIO 1: At 2200, you enter the room and the patient states pain is now 10/10 after not having any pain for 3 hours. Call Rapid response. Rapidly prioritize the following: SCENARIO 2: Mr. Martinez was taken emergently to the Cath-lab and had 3 stents inserted in his heart. The pain was relieved post-op. He has been informed that for the next 18 months he should take antithrombotic therapy daily. SCENARIO 3: Mr. Martinez will now start taking long term antithrombotic therapy. He is anxious that he will forget to take it or take the wrong dose. He tells you he wished he "had died from the attack...I'll never be the same. SCENARIO 4: Mr. Martinez lab work comes back post-stent placement. Rank as most concerning for labs. SCENARIO 5: Mrs. Martinez is visiting her husband, who appears to be ignoring any attempts at conversation. Upon completion of the shift assessment, Mrs. Martinez quietly asked "my husband is telling me he is ready to get me home, that he is missing me. Should I be concerned about having sex with him? Could he have another heart attack?"

Educational Needs increased Fall Risk increased Health increased Neurological normal Pain level normal Psychological Needs normal NURSING CONCERNS: Physiological: Acute Pain T Altered body image F Anxiety T Disturbed thought process F Impaired gas exchange T Impaired tissue perfusion T Ineffective health maintenance T Powerlessness T Safety: Drug therapy T Risk for social isolation F ACTIONS IN ORDER:1 Assess airway, breathing, circulation. Administer oxygen therapy to make sure oxygen saturation is greater than 90%. Ensure continuous EKG monitoring. Provide Morphine Sulfate IVP as prescribed. Reassess patient's vital signs and pain level ACTIONS IN ORDER:2 Assess for the abrupt cessation of pain Initiate IV Heparin. Give ASA. Observe for bleeding. Monitor aPTT ACTIONS IN ORDER:3 Provide emotional support. Assess Mr. Martinez's willingness to learn. Provide introductory information on prescribed antithrombotic medication. Report Mr. Martinez's emotional distress to Case Management. Document all findings. ACTIONS IN ORDER:4 Troponin 1.0 mg/mL. CPK: 360 mcg/mL. CK-MB6.8 Serum Potassium 4.2 mEq/L. Serum Sodium 142 mEq/L. ACTIONS IN ORDER:5 Clarify with Mrs. Martinez that she is asking if it is okay to resume sexual relations with her husband upon discharge Promote open communication between Mr. and Mrs. Martinez. Explain to Mr. and Mrs. Martinez the disease process following a myocardial infarction. Discuss physical limitations following a myocardial infarction. Provide information to Mr. and Mrs. Martinez regarding support groups.

Kenny Barrett REPORT/ ACCUITY 64 years old, was admitted for observation of initial administering of BP his treatment with blood pressure of 220/124 after visiting his doctor for a routine physical. ECG was unremarkable. No past history of HTN. Past medical history includes hyperlipidemia and a history of 1 pack a day smoker for the past 20 years. Vital signs are Temp 98.9F, BP 178/90, P 88, RR 18 SaO2 95% on Room air. IV with NS @ 125 mL/ hr. Patient has been complaining of a headache and dizziness. He is a patient of Dr. Adams. SCENARIO 1 You have entered the room to administer the patient's morning medication, atenolol 50mg. The CNA reports the blood pressure was 130/86 an hour ago. SCENARIO 2: You return to patients room 20 minutes later and the patient is pale, lying in bed, feels light-headed and nauseated when he sits up. SCENARIO 3 Call the Healthcare Provider and provide the following information utilizing SBAR: SCENARIO 4: The Healthcare Provider prescribed the following orders, place in implementation sequence: SCENARIO 5: Upon entering the patient's room, he is threatening to go outside and smoke, agitated and demanding to be discharged or have a cigarette. Vital signs are: BP: 128/82, P: 90, R: 22, T: 99.2.

Educational Needs increased Fall Risk increased Health increased Pain level Increased Psychological Needs normaL sensorium increased NURSING CONSIDERATION Physiological: Acute Pain T Bleeding risk F Safety: Deficient knowledge T Fall risk T Peripheral neurovascular dysfunction F ACTIONS 1 Perform hand hygiene. Re-assess blood pressure and pulse. BP is 190/110, pulse is 86. Evaluate patients understanding of the medication and provide education. Administer the medication. Document on the MAR and education in the chart. ACTIONS 2: Retake vital signs (BP is 110/70, pulse is 94) Instruct patient not to get out of bed without assistance. Perform comfort measures. Request CNA to remain with patient. Notify the healthcare provider using SBAR. ACTIONS 3 Patient Kenny Barrett is nauseated and complains of dizziness when they sit up. Patient was admitted yesterday afternoon with hypertension, BP 178/90, pulse 88, hypertension was undiagnosed and was started on Atenolol 50mg, once a day. This is his second dose. IV 20 gauge, left forearm NS 125ml/hr. Current vital signs are BP:110/70, Pulse: 94. Patient is pale, dizzy, and nauseated Request possible change in medication and more frequent vital signs. ACTIONS 4 Take vital signs now and Q4 hours. Maintain strict I&O. 500 mL normal saline bolus. Hold next dose of Atenolol if BP is <130/80. Contact Healthcare Provider if patient status does not improve. ACTIONS 5: Assess stress level. Communicate with the patient therapeutically Discuss willingness for alternatives to smoking. Educate patient to why he cannot go outside and smoke. Contact Healthcare Provider for Nicotine patch order

SARAH KATHRYN HORTON REPORT/ACCUITY Sarah Kathryn Horton, 25 -year old graduate student was brought to the emergency room via ambulance after being shot on the local college campus. Sarah was admitted to Med-Surg at 2am. She has two through and through gun-shot wounds. One to her right thigh and one to her right shoulder. She has a 20- gauge peripheral IV to left forearm with 75 mL/hr. of 0.9% saline infusing. Vital signs are stable at this time, alert and oriented x3, reports pain 6/10. She remains tearful and has been told that her best friend died on the scene. SCENARIO 1: You hear a scream coming from Mrs. Horton's room. Upon entering the room, it was noted that she appeared to be asleep, eyes closed, possibly experiencing a bad dream. SCENARIO 2: Ms. Horton did not rest well last night, and woke up frequently with episodes of crying. This morning, at shift report, she states that she is scared to leave the hospital after the shooting incident. Patient is complaining of pain in her shoulder and thigh 7/10. SCENARIO 3: HealthCare Provider Orders: 1. Dressing Change q 24 hours to Right Thigh and Right Shoulder 2. Pre medicate Morphine Sulfate 4 mg IV 15 minutes prior to dressing change 3. Wet to dry dressing with triple antibiotic ointment to wounds 4. Sulfamethoxazole 800 mg Trimethoprim 160 mg (Bactrim DS) 1 tablet PO daily 5. Consult Psychology for referral 6. Encourage PO fluids. SCENARIO 4: Ms. Horton's wounds are now stable enough to be discharged home with the following orders: 1. Discharge home 2. Paroxetine (Paxil) 30 mg PO everyday. Follow up with regular healthcare provider in1 week 4. Sulfamethoxazole 800 mg Trimethoprim 160 mg (Bactrim DS) 1 tablet PO daily for 10 days 5. Hydrocodone 5 mg Acetaminophen 325 mg (Norco 5 mg) 1-2 tablets every 3-4 hours PRN moderate to severe pain # 30. SCENARIO 5: The nurse has Ms. Horton in the wheelchair ready to be taken down to the lobby by the UAP. As Ms. Horton is waiting by the exterior hospital door, construction workers are on the road working with a jackhammer. Ms. Horton hears the jackhammer and then screams and dives to the floor

Educational Needs increased Fall Risk increased Health increased Pain level increased Psychological Needs increased sensorium normal NURSING CONSIDERATIONS Physiological: Acute Pain T Anxiety T Body Image Disturbance F Disturbed personal identity T Fatigue F Impaired Physical Mobility T Impaired skin integrity T Risk for decreased oxygenation F Risk for post trauma syndrome T Safety: Alteration of Protective Mechanisms T ACTIONS IN ORDER:1 Wash hands prior to entering the room. Assess respiratory status by observation. Do not disturb the patient. Reduce stimuli in the patient room. Documents all findings. ACTIONS IN ORDER;2 Wash hands prior to entering the room. Assess Ms. Horton's orientation. Medicate patient. Attempt de-escalation strategies. Documents all findings. ACTIONS IN ORDER;3 Gather supplies needed for dressing change. Wash hands upon entering the room. Explain the procedure to Ms. Horton. Provide Morphine Sulfate 4 mg IV. Perform dressing change ACTIONS IN ORDER:4 Educate Ms. Horton that paroxetine (Paxil) is to be taken as ordered. Reinforce past coping mechanisms that have been effective. Educate family regarding active listening and open communication. Educate the family regarding intervention and support for Ms. Horton. Documents all interactions. ACTIONS IN ORDER:5 Assess Ms. Horton's orientation status. Use therapeutic communication to re-orient and provide reassurance. Assist Ms. Horton back into the wheelchair Escort patient to the ER for a physical and psychological evaluation. Provide report to ER nurse.

KAREN COLE REPORT/ ACCUITY Karen Cole, 56 year old female, Karen Cole, a school principal at White House High School. Admitted directly from the Dr.'s office to the IMCU after initial complaint for tightness in her chest, denies pain, and slight shortness of breath. Vital signs are BP: 168/92, P: 90, R: 24, T: 98.6. Her husband insisted that she come. She is insisting that she will only stay 12 hours, because she has to be back to school in the morning. SCENARIO 1; Patient arrives at the unit with her husband. You have introduced yourself to the patient, and she is now in bed. SCENARIO 2: EKG and lab findings return 30 minutes after arrival. EKG: abnormal with slight ST elevation, initial troponin 0.39 NG per mL at 1400, CBC and BMP within normal limits, CKMB: 6 Ng/mL. Mrs. Cole says her chest tightness has increased and is now having pains radiating down her left arm as she becomes more anxious and agitated. Nitroglycerin tablet sublingual given times 3 per Dr.'s order with minimal relief. SCENARIO 3: Patient has arrived from Cath Lab after having 2 cardiac stents placed from femoral access. SCENARIO 4: Patient pushes the call light and is complaining of pain at her IV site. You examine and the IV has infiltrated. SCENARIO 5: 12 hours after initial labs, troponin is 1.02, EKG ST segments are normal, patient is started on antithrombotic therapy and scheduled to begin discharged to a 60-day cardiac rehab program.

Educational Needs increased Fall Risk normal Health increased Neurological NORMAL Pain level normal Psychological Needs normaL sensorium normal NURSING CONCERNS: Physiological: Acute Pain F Impaired coping T Nausea F Risk for impaired comfort T Safety: Fall, for Risk F Infection risk T Risk for constipation F Risk for injury T ACTIONS 1 Apply O2 at 2 L nasal-cannula. Connect patient to cardiac monitor, assess vital signs Complete full assessment. Obtain IV access and draw initial labs Orient patient and husband to the unit ACTIONS 2: Give IV morphine, 2mg IVP. Reassess vital signs and chest pain. Notify Cath Lab for stat cardiac cath. Obtain informed consent for cardiac cath Transport patient to Cath lab with Cardiac monitors. ACTIONS 3: Take vital signs. Post-op assessment. Ensure pressure dressing is in place. Instruct patient to lie in supine position for 6 hours. Assess pain and cardiac rhythm Q 15 minutes. ACTIONS 4: Explain the necessary procedure. Perform hand hygiene and don gloves. Remove infiltrated IV. Don new gloves. Insert new IV above prior site or opposite limb. ACTIONS 5: Assess patient and families readiness to learn. Provide patient post MI education. Patient and family should verbalize understanding of discharge instructions. Schedule cardiac rehab. Document.

JOYCE WORKMAN REPORT/ ACCUITY Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. She has been documented as being obese, new onset hypertension, polyuria, and a rash on her abdomen. She was asymptomatic upon arrival. She was admitted yesterday for stabilization of her glucose levels, and assist her with lifestyle modification. She states she leads a sedentary lifestyle as a bank officer. Her HbA1C is 10%. SCENARIO 1: Mrs. Workman presented to the diabetes clinic and provided a 24- hour food recall. She was then sent to the lab for ordered lab tests. She is to notify the nurse upon return to the clinic from the lab. Patient has requested more information on her diabetes and states she does not understand why she "should be concerned" with blood glucose control in both the short and long term. SCENARIO 2: The nurse is providing information on nutrition to assist Mrs. Workman in managing her diabetes. SCENARIO 3 Mrs. Workman presented to the Diabetes Clinic for further evaluation of her diabetes, and lifestyle changes. She is planning on attending several of the classes that are being offered. Patient is requesting information on appropriate exercise programs. She has attended the Diabetic meal prep class, but still struggles with her diagnosis of diabetes. SCENARIO 4 Day 3 of hospitalization at 12:30, Mrs. Workman calls the nurse and complains of cool clammy skin, anxious, weak, hungry but nauseous, and slightly confused. April 10, 1245, Blood Glucose level: 40 mg/dL Healthcare Provider has ordered: 1. Hypoglycemia protocol for BG level < 60 mg/dL 2. Regular insulin SQ 20 units for BG level > 160 mg/dL 3. Monitor BG levels q 4 hours and PRN 4. IV fluids D5 0.45% NS at 125 mL/hour via peripheral line 5. 1800 calorie ADA diet and teach the patient about diet changes. SCENARIO 5: 3 months later, Mrs. Workman has returned to the Diabetes Clinic having lost 20 pounds and is requesting to stop taking the Metformin (Glucophage). HbA1C is 7.5 %. She is also complaining of new onset diarrhea.

Educational Needs increased Fall Risk normal Health increased Neurological normal Pain level normal Psychological Needs normaL sensorium normal NURSING CONSIDERATIONS: Physiological: Enhanced readiness for learning T Ineffective health maintenance T Safety: Deficient fluid volume F Imbalanced Nutrition T Risk for injury T Social isolation F ACTIONS 1: Ask Mrs. Workman to explain what she knows about diabetes. Explain in layman terms what Diabetes is and how it can adversely affect the body if left untreated. Discuss lifestyle choices that can lead to type II diabetes. Discuss lifestyle changes that can be beneficial in the management of type II diabetes. Document teaching and understanding of teaching using teach back process. ACTIONS 2: Assess Mrs. Workman's knowledge of nutrition and preferred foods. Ask Mrs. Workman for a 24- hour diet recall. Educate Mrs. Workman on healthier options based on the 24-hour diet recall. Provide Mrs. Workman with a Mediterranean style diet plan Ask Mrs. Workman to demonstrate understanding using the teach back method. ACTIONS 3: Assess the patient's preferred exercise regimen. Ensure the patient does not have pre-existing conditions that would limit exercise routines. Provide an exercise routine that has been developed in conjunction with Mrs. Workman. Review with Mrs. Workman safety measures related to blood glucose levels when exercising Use teach back method and document education provided. actions 4 Assess patient's blood glucose level. Provide a 20 -gram carbohydrate liquid for consumption. Provide another 20-gram carbohydrate liquid for consumption in 15 minutes for unresolved symptoms. Reassess the blood glucose level in 15 minutes. Provide additional teaching to the patient regarding prevention strategies for hypoglycemia. ACTIONS5; Assess Mrs. Workman' s understanding of her medication, diet, and exercise regimen Explain to Mrs. Workman about carbohydrate foods causing GI upset. Explore new ways of cooking for diabetes management Provide information to Mrs. Workman on support groups for diabetes. Document education provided

Roger Clinton REPORT/ACCUITY Roger Clinton, 57-year-old male construction worker arrives at 0600 to be prepared for a partial thyroidectomy to determine if he has cancer. His past symptoms for three months have been that he noticed a slight hoarseness in speaking, a slight dry cough not related to a cold, and upon examination had a "pea-size lump on the center of his neck". His Endocrinologist had a radioiodine scan performed that showed a suspicious area. The plan is to obtain a biopsy from several areas of the thyroid gland, and hopefully to leave as much as possible in place. Roger knows that it will take three days after surgery to determine if he has cancer, but does not understand the implications resulting from a thyroidectomy. (Lifetime thyroid replacement medication.) SCENARIO 1: You are preparing the patient for surgery List in order what you, as his pre-op nurse, will be expected to do: SCENARIO 2: The patient has been taken to surgery, and now three hours later returns to his room from the PACU. The surgical team gives the following report: Uneventful partial thyroidectomy returning to his room. Roger is awake, alert, and oriented times 4. Neck dressing is in place with slight pinkish drainage. He does not have a Foley catheter in place, but has voided 400 mL once since surgery. Skin is warm and dry. IV D5 .45 NS at 100 per hour and had 2000 MLs during surgery. He was medicated for pain with Fentanyl 100 mcg IV. He was also given Zofran by Anesthesia 4mg. Vital signs are B/P 168/88, P: 112, R: 28, T: 99.2 F, 37.3 C, PaO2: 92% List in order what would be most concerning. SCENARIO 3: Three hours after surgery, Mr. Clinton begins complaining of increased pain and restlessness. The surgical site, upon inspection, is heavily saturated with bright red blood. The amount of bleeding has doubled over the last hour. His vital signs are now; B/P 142/78, Pulse 122, Resp 24, Temp 99.0 F, 37.2 C, PaO2 94%. SCENARIO 4: The surgeon happens to be on the unit, and sees Mr. Clinton immediately. He determines that Mr. Clinton must go back to surgery now to stop bleeding from the site. SCENARIO 5: Mr. Clinton returns to his room two hours later, and you receive a report from the Surgical Recovery unit nurse: "Patient did fine with second event today which was isolated to a simple bleed on his thyroid which needed cauterization. He is alert and cooperative, dressing dry and intact, Received 1000 cc of D5W and .5 NS during surgery. He has not voided at this time. He was given 50mcg fentanyl for pain and 25mg of Demoral for post-op shivering thirty minutes ago via IV. He appears comfortable at this time. He should back to the room in the next 15 minutes if I can find someone to escort him. His surgeon Dr Smith is writing orders now."

Educational Needs increased Fall Risk normal Health increased Neurological normal Pain level normal Psychological Needs normal NURSING CONCERNS: Physiological: Acute pain F Bleeding, risk for T Chronic pain F Impaired comfort, risk for T Impaired mobility, risk for T Nausea, risk for T Safety: Deficient knowledge T Infection, risk for T ACTIONS IN ORDER:1 Wash hands and wear PPE as indicated Explain to Roger that he needs to empty his bladder and ask him to put on a patient gown and remove all jewelry Obtain and verify operative consent and confirm NPO status since Mid-night Initiate IV Orient patient on what to expect as he awaits anesthesia and the OR transport staff to take him to surgery ACTIONS IN ORDER:2 Orient Roger back to the floor Take his vital signs Observe and mark dressing for drainage or bleeding Assess pain level and when last medicated Fluid status and time since last voided ACTIONS IN ORDER:3 Head-to-toe assessment of patient Reinforce dressing and document amount/time of dressing pads applied Notify Surgeon with a STAT call Notify Charge nurse of potential bleed occurring Instruct patient to remain in bed until HCP arrives ACTIONS IN ORDER:4 Take vital signs Keep Mr. Clinton NPO Reinforce dressing and document amount/time of dressing pads applied Initiate secondary large bore IV site Witness signing of a new operative consent form with Surgeon present ACTIONS IN ORDER;5 Initiate head-to-toe assessment Check operative site dressing Assess for pain and medicate if needed Review new orders from Surgeon Encourage Mr. Clinton to void and not to get out of bed without assistance.

Linda Pittmon ACCUITY/REPORT Linda Pittmon, a 74 -year old female patient who is a noncompliant diabetic, and frequently stays at the local homeless shelter. She has been admitted to the floor with complaints of numbness in her right foot and ankle. Mrs. Pittmon states she has had numbness for years but "now I can't feel it at all, and my toes don't look the right color.". Scenario 1 Pt presents to the unit c/o numbness in the rt foot and ankle and toes "not looking the right color". All 5 toes on the right foot are necrotic, absent pedal pulses, skin cold to touch, appearance dry, cracked and black up to mid-calf. Foul odor noted w/ green drainage coming from toenail beds. Doctor orders 1.) IVF 0.9% NS peripheral line @ 100mL/hr 2.) CBC, CMP, Blood culture x 2, Hgb A1C 3.) CT scan of rt lower leg 4.) Blood lab tests 5.) Levofloxacin (Levaquin) 750 mg IV q 24hrs Scenario 2 Pt speaking incoherently and is exhibiting rapid eye movement w/ a blank stare. An empty syringe is noted in the bed. Pt does respond partially to commands. Brisk peripheral reflexes, eyes equal, round, dilated Scenario 3 8 hrs later, pt is fidgety and is observed picking at her skin and clothes. The pt states, "I am sick to my stomach and feel like I have bugs crawling all over me!!!" Scenario 4 Surgery called to the unit the Ms. Pittman is scheduled at 1300 for a BKA. Scenario 5 Post op day 3 time for dressing change stump. Pt sates pain has been managed through the night. Pulses above the stump are palpable at 2+, skin is warm and dry. Pt states she has noted some "toe pain" but that it has been <3 on a scale of 1-10.

Educational Needs increased Fall Riskincreased Health increased Neurological increased Pain level normal Psychological Needs normal NURSING CONSIDERATIONS: Physiological: Anxiety F Disturbed body image T Disturbed sleep pattern F Impaired Memory F Ineffective health maintenance T Risk for malnutrition T Safety: Impaired tissue integrity T Isolation Precautions F Risk for physical injury T Risk for Urinary Retention F Self-care deficit T ACTIONS IN ORDER:1 Wash hands and don gloves. Obtain blood for lab testing and blood culture # 1. Obtain blood from secondary site for blood culture #2. Initiate IV fluids to peripheral site Administer levofloxacin as ordered. ACTIONS IN ORDER: 2 Assess the vital signs and perform a neurological focused assessment. Place the syringe in a biohazard bag and place a patient identification label on bag. Ask the patient if she knows where the syringe came from and what was in the syringe. Notify the charge nurse and house supervisor of the syringe found in bed. Notify the physician of assessment findings and await further orders. ACTIONS IN ORDER:3 Assess vital signs and perform head to toe assessment. Therapeutic communication with patient. Call Healthcare Provider for change in health status and receive orders for anxiety medication. Prescribed medication for anxiety must be administered Assess for therapeutic response to medications. ACTIONS 4; Ask Mrs. Pittmon if she remembers the conversation with the physician and if she has any further questions that need to be addressed. Perform pre op checklist. Ensure signed consents are on the chart. Ensure type and cross match for blood products is complete and results are in electronic medical record. Have IV antibiotics available to administer when surgery calls for the patient to be transferred to pre op area. ACTIONS 5: Pre-medicate for pain with prescribed medication Don clean gloves to remove old dressing. Monitor neurovascular status assessing skin color, temperature, sensation, pulses above amputation. Don 2nd set of clean gloves to provide stump care. The wound has been sutured and is not an open wound/stump. Elevate stump and rewrap with a dry clean dressing.