Guaranteed Success
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
Physiological-
Acute Pain: True
Electrolyte Imbalance: False
Imbalanced Nutrition: False
Impaired Mobility, Risk for: True
Impaired Skin Integrity, Risk for: False
Impaired Urinary Elimination: True
Safety-
Fall, Risk for: True
Sleep Deprivation: False
Scenario #1
Wash & glove
Vital assessment
Administer
,Reassess pt.
Document
Scenario #2
Vital assessment
Notify Dr.
Administer new
Reassess pt.
Scenario #3
Use therapeutic
Obtain urinary
Assist pt.
Remain w/ pt.
Document
Scenario #4
Use therapeutic
Educate pt.
Evaluate understanding
Contact dietary
Document
Scenario #5
D/C instruction
Evaluate understanding
,Escort pt.
Document
Notify housekeeping
Ramona Stukes Educational Needs: Increased acuity
Fall Risk: Increased acuity
Health Change: Increased acuity
Pain Level: Increased acuity
Psychological: Normal acuity
Sensorium: Normal acuity
Keaton Henderson Educational - increased
Fall Risk - increased
Health Change - increased
Neurological - normal
Pain - normal
Psychological Needs - normal
Acute pain
Bleeding, risk for
Impaired comfort
Fall risk
Scenario #1
Introduce
Take vitals
, Auscultate lungs
Inspect pleurovac
Mark drainage level
Scenario #2
Assess VS
Assess insertion site
Check pleurovac
Administer pain meds
Encourage use of IS
Scenario #3
admin 100%
Call rapid
Assess for shift
Auscultate
Assess chest drainage
Scenario #4
Obtain 16 gauge angiocath
Explain to pt
Set up sterile
Obtain & fill
Assist with insertion
Scenario #5