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 l...
swift river med surg pt scenarios
Correct 100%
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 - ANSWER Educational Needs Increased acuity
Fall Risk Increased acuity
Health Change Increased acuity
Pain Level Increased acuity
Psychological Needs Normal acuity
Sensorium Normal acuity
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. - ANSWER
Scenario 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 - ANSWER Educational
Needs Increased acuity
Fall Risk Normal acuity
Health Change Increased acuity
Pain Level Increased acuity
Psychological Needs Increased acuity
Sensorium Normal acuity
Marcella Como - ANSWER Physiological
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
Compromised Family Coping True
Powerlessness False
Social Isolation True
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