Swift River Estelle Hatcher Room 301 Scenario 1-5 NEW 2022

Estelle Hatcher Room 301
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
You responded correctly to 5 out of 6 evaluations:
CategoryYour
response Explanation
Educational NeedsIncreased acuityStatus assessment reports first day post-op appendectomy, NPO, NG-tube to low continuous suction.
Fall RiskIncreased acuityStatus assessment reports first day post-op appendectomy, NPO, NG Tube, IV- left forearm, ambulates with assistance.
Health ChangeIncreased acuityStatus assessment reports first day post-op appendectomy; NPO, NG-tube to low continuous suction.
Pain LevelNormal
acuityNo indication of pain at this time
Psychological NeedsNormalStatus assessment reports no indication of increased psychological acuity.
SensoriumNormalStatus assessment reports no indication of increased sensorium acuity.
Physiological
DescriptionYour
Response Explanation
Activity IntoleranceFalseStatus assessment states patient can ambulate with minimal assistance.
Acute Pain falsePatient would be at Risk for pain as there is no DescriptionYour
Response Explanation
indication of pain.
Diarrhea FalseStatus assessment reports no indication of diarrhea.
Electrolyte Imbalance,
Risk forTrueStatus assessment reports placement of NG-tube.
Impaired ComfortTrueStatus assessment reports discomfort of NG-tube.
Impaired MobilitytrueStatus assessment states patient needs assistance to ambulate.
Safety
DescriptionYour
Response Explanation
Deficient KnowledgeTrueStatus assessment reports patient has had recent surgery and NG Tube.
Fall, Risk forTrueStatus assessment reports patient has an IV line and NG Tube which are trip hazards.
Fear FalseStatus assessment reports no indication of fear.
Ineffective Self-Health
ManagementFalseStatus assessment reports no indication of nursing dx.
Infection, Risk forTrueStatus assessment reports surgical incisions.
Sleep Deprivation FalseStatus assessment reports no indication of inability to sleep.
Scenario 1
Ms. Hatcher is second day post-op and has a nasogastric tube set to
gravity drainage only. She presses the call light with questions about who
her nurse will be and has concerns about her NG-tube.