Guaranteed Success
Ann Rails Educational - Increased
Fall Risk - Increased
Health Change - Increased
Pain - Increased
Psychological Needs - Normal
Sensorium - Normal
Ann Rails Acute pain
Impaired comfort
Impaired mobility
Disturbed sensory perception
Fall, risk for
Peripheral neurovascular dysfunction
Ann Rails Scenario #1
Use therapeutic
Educate pt.
Evaluate pt. learning
Place call light
Document
Scenario #2
Wash and glove hands
Assess
,Provide comfort measures
Notify doctor
Document
Scenario #3
Listen to pt. concerns
Reassure pt. of options
Notify lead nurse/doctor
Contact Social Services
Document
Scenario #4
Wash and glove hands
Visual assessment
Do not disturb
Verify Call Light
Document
Scenario #5
Assess for bowel sounds
Encourage fluids/fiber/ambulation
Evaluate pt. understanding
Attain fluids/fiber diet
Document
Arthur Thomason Educational - increased
,Health change - increased
LOC - increased
Pain - increased
Psychological needs - increased
Safety - increased
Arthur Thomason Impaired confort
Impaired gas exchange
Ineffective airway clearance
Shock, risk for
Anxiety/fear
Failure to thrive, risk for
Arthur Thomason Scenario #1
Assess
Replace O2
Use therapeutic
Notify Dr. and charge nurse
Scenario #2
Remind physician
Explain to physician
Assist physician
Obtain recent
Reassure pt.
, Scenario #3
Tap pt.
Elevate HOB
Call rapid response
Start secondary
Remain with pt.
Scenario #4
Provide verbal report
Emergency intubation
Assume role
Obtain pt. record
Provide information
Scenario #5
You explain that his condition
You explain that he is receiving
You have them remain with you
You escort them with you
You call his doctor
Calvin Umbyuma Educational - increased
Fall Risk - normal
Health Change - increased
Pain - increased
Psychological needs - normal