Module 6 Winter 19
In class Case Studies
Case Study 1:
Bernadette Jackson
Bernadette Jackson is an 85-year-old African American female who presented to the emergency department at 1130
Thursday morning with weakness, lethargy, and abdominal discomfort. Medication review and bladder scanning
revealed polypharmacy-related urinary retention. An indwelling catheter was placed. Mrs. Jackson was admitted to
the inpatient medical unit for rehydration, IV antibiotics, and monitoring. The scenario takes place on Thursday at
1500, at which point Mrs. Jackson develops acute confusion. Urinalysis results confirm probable infection. During
this scenario, students will have the opportunity to assess, plan, prioritize, and implement care for an older adult
patient experiencing acute confusion related to a urinary tract infection.
SBAR Current Thursday 1500 Admission Thursday 1345
Hand-Off day and
time: day and time:
Situation Name: Bernadette Jackson
Age: 85 Sex: Female Ethni African American Religion: Christian
city:
Provider: Kenneth Young, NP
Admissi Dehydration, urinary retention, and possible urinary tract infection
on
diagnosis
:
Backgroun Pertinent Mixed urinary incontinence; primary care provider started her on oxybutynin 1 week ago. For the past
d medical 5 days she has also taken over-the-counter loratadine for seasonal allergies. An interaction of the two
history: medications resulted in urinary retention. This morning she presented to the emergency department
with weakness, lethargy, and abdominal pain. A bladder scan revealed 620 mL of retained urine. A
catheter was placed which drained all of the urine. A urine sample was sent for urinalysis.
Pertinent Widowed. Lives in assisted living complex.
social
history:
Allergies No known drug allergies. Has environmental (seasonal) allergies.
:
Code Do not resuscitate
status:
Vital Time: 1400 T: 99.2 F BP: 138/68 P: 90 RR: 24 O2 S 93%
signs (m 37.3
ost C at:
recent):
Oxygen Mode: Room air LPM Not applicable
therapy: :
Pain: Rating 3/10 Most recent pain medication: Acetaminophen 500 Time 1230
:
mg :
Other Daily medications taken this morning at home
recent
References
Simulation Learning Center. (2018). Simulation scenarios: Medical surgical. Retrieved from:
http://coursewareobjects.elsevier.com/objects/simcenter/medical-surgical/medical-
surgical_nursing_simchart/mod43/43s01l0113.php#
, Module 6 Winter 19
In class Case Studies
medicati
on:
IVs: Site: Right Typ 20-gauge PIV Assessm Intac Fluid: 0.9%
antecubit e:
al ent: t, normal
pate saline IV
nt at 100
mL/hr
Drains Site: None Typ Not applicable Assessm Not applicable
and e:
tubes: ent:
Wounds: Site: None Typ Not applicable Assessm Not applicable
e:
ent:
ADLs: Diet: Regular diet, encourage fluids Activity: Bathroom privileges with
assist
Restricti Isolation: Standard Fall High
ons:
risk:
Assessm Neurologic: Talkative during admission history. Oriented x 2. Reorients easily.
ents:
Cardiac: S1 S2, no murmurs; diminished pulses, 1+ radial and dorsalis pedis bilaterally
Respiratory: Lungs clear
GI/GU: Complaining of "burning" at urethral site. Urinary catheter in place. Urine output over
the last 2 hours has been about 30 mL per hour. The catheter bag was last emptied at
1400.
Integumentar Dry, intact; no skin breakdown noted
y:
Ortho/Mobilit Moderate assist x 1 during transfer to the bed
y:
Psychosocial: Emotionally stable; neighbor at bedside
Other:
Labs and The urinalysis has just returned but I have not had time to look at it. Can you please review it and call
diagnosti Kenneth Young, NP, with the results? Labs completed earlier in the day indicate a possible infection.
cs:
Assessment Nurse's Mrs. Jackson appears weak and slightly confused, possibly related to an infection. Neighbor states
assessme that this is new for Mrs. Jackson.
nt:
Recommen Plan of According to the progress note, the plan is for overnight monitoring. Urology has been consulted to
dation care: see her tomorrow, and then will likely discharge to home.
Tests/res Complete blood count and chemistry panel in the morning.
ults
pending:
Orders I have completed the admission nursing history and medication reconciliation form. I have not
pending reviewed the admission orders yet.
References
Simulation Learning Center. (2018). Simulation scenarios: Medical surgical. Retrieved from:
http://coursewareobjects.elsevier.com/objects/simcenter/medical-surgical/medical-
surgical_nursing_simchart/mod43/43s01l0113.php#
In class Case Studies
Case Study 1:
Bernadette Jackson
Bernadette Jackson is an 85-year-old African American female who presented to the emergency department at 1130
Thursday morning with weakness, lethargy, and abdominal discomfort. Medication review and bladder scanning
revealed polypharmacy-related urinary retention. An indwelling catheter was placed. Mrs. Jackson was admitted to
the inpatient medical unit for rehydration, IV antibiotics, and monitoring. The scenario takes place on Thursday at
1500, at which point Mrs. Jackson develops acute confusion. Urinalysis results confirm probable infection. During
this scenario, students will have the opportunity to assess, plan, prioritize, and implement care for an older adult
patient experiencing acute confusion related to a urinary tract infection.
SBAR Current Thursday 1500 Admission Thursday 1345
Hand-Off day and
time: day and time:
Situation Name: Bernadette Jackson
Age: 85 Sex: Female Ethni African American Religion: Christian
city:
Provider: Kenneth Young, NP
Admissi Dehydration, urinary retention, and possible urinary tract infection
on
diagnosis
:
Backgroun Pertinent Mixed urinary incontinence; primary care provider started her on oxybutynin 1 week ago. For the past
d medical 5 days she has also taken over-the-counter loratadine for seasonal allergies. An interaction of the two
history: medications resulted in urinary retention. This morning she presented to the emergency department
with weakness, lethargy, and abdominal pain. A bladder scan revealed 620 mL of retained urine. A
catheter was placed which drained all of the urine. A urine sample was sent for urinalysis.
Pertinent Widowed. Lives in assisted living complex.
social
history:
Allergies No known drug allergies. Has environmental (seasonal) allergies.
:
Code Do not resuscitate
status:
Vital Time: 1400 T: 99.2 F BP: 138/68 P: 90 RR: 24 O2 S 93%
signs (m 37.3
ost C at:
recent):
Oxygen Mode: Room air LPM Not applicable
therapy: :
Pain: Rating 3/10 Most recent pain medication: Acetaminophen 500 Time 1230
:
mg :
Other Daily medications taken this morning at home
recent
References
Simulation Learning Center. (2018). Simulation scenarios: Medical surgical. Retrieved from:
http://coursewareobjects.elsevier.com/objects/simcenter/medical-surgical/medical-
surgical_nursing_simchart/mod43/43s01l0113.php#
, Module 6 Winter 19
In class Case Studies
medicati
on:
IVs: Site: Right Typ 20-gauge PIV Assessm Intac Fluid: 0.9%
antecubit e:
al ent: t, normal
pate saline IV
nt at 100
mL/hr
Drains Site: None Typ Not applicable Assessm Not applicable
and e:
tubes: ent:
Wounds: Site: None Typ Not applicable Assessm Not applicable
e:
ent:
ADLs: Diet: Regular diet, encourage fluids Activity: Bathroom privileges with
assist
Restricti Isolation: Standard Fall High
ons:
risk:
Assessm Neurologic: Talkative during admission history. Oriented x 2. Reorients easily.
ents:
Cardiac: S1 S2, no murmurs; diminished pulses, 1+ radial and dorsalis pedis bilaterally
Respiratory: Lungs clear
GI/GU: Complaining of "burning" at urethral site. Urinary catheter in place. Urine output over
the last 2 hours has been about 30 mL per hour. The catheter bag was last emptied at
1400.
Integumentar Dry, intact; no skin breakdown noted
y:
Ortho/Mobilit Moderate assist x 1 during transfer to the bed
y:
Psychosocial: Emotionally stable; neighbor at bedside
Other:
Labs and The urinalysis has just returned but I have not had time to look at it. Can you please review it and call
diagnosti Kenneth Young, NP, with the results? Labs completed earlier in the day indicate a possible infection.
cs:
Assessment Nurse's Mrs. Jackson appears weak and slightly confused, possibly related to an infection. Neighbor states
assessme that this is new for Mrs. Jackson.
nt:
Recommen Plan of According to the progress note, the plan is for overnight monitoring. Urology has been consulted to
dation care: see her tomorrow, and then will likely discharge to home.
Tests/res Complete blood count and chemistry panel in the morning.
ults
pending:
Orders I have completed the admission nursing history and medication reconciliation form. I have not
pending reviewed the admission orders yet.
References
Simulation Learning Center. (2018). Simulation scenarios: Medical surgical. Retrieved from:
http://coursewareobjects.elsevier.com/objects/simcenter/medical-surgical/medical-
surgical_nursing_simchart/mod43/43s01l0113.php#
