swift river med surg pt scenarios
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 correct answerEducational Needs Increased acuity
Fall Risk Increased acuity
Health Change Increased acuity
Pain Level Increased acuity
Psychological Needs Normal acuity
Sensorium Normal acuity
Ramona Stukes correct answerPhysiological
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
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. correct answerScenario 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
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 correct answerEducational Needs Increased acuity
Fall Risk Normal acuity
Health Change Increased acuity
Pain Level Increased acuity
Psychological Needs Increased acuity
Sensorium Normal acuity
Marcella Como correct answerPhysiological
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
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 correct answerEducational Needs Increased acuity
Fall Risk Increased acuity
Health Change Increased acuity
Pain Level Increased acuity
Psychological Needs Normal acuity
Sensorium Normal acuity
Ramona Stukes correct answerPhysiological
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
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. correct answerScenario 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
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 correct answerEducational Needs Increased acuity
Fall Risk Normal acuity
Health Change Increased acuity
Pain Level Increased acuity
Psychological Needs Increased acuity
Sensorium Normal acuity
Marcella Como correct answerPhysiological
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
