You begin your shift assessment w/ Mr. Jones
Mr. Jones is scheduled for a full body CT scan. Mr. Jones stated to the nurse that he "was scared to leave the room." Further questioning and clarification revealed Mr. Jones does not want to be alone and is afraid of being hurt
Later in the evening Mr. Jones falls on his way to the bathroom
Mr. Jones is resting quietly in the bed, R 22, slightly labored, color pink. Eyes closed. Upon assessment, Mr. Jones was noted to have bilateral wheezing, R 24, some use of accessory muscles w/ respiration's, dullness to percussion in the left lower lobe, an an unproductive cough. Based on assessment, nebulizer tx administered per MD orders.
Mr. Jones is now more alert and states he does not see the point in living anymore and wishes he would just die quietly. He asks to speak to a clergy member. He does not want to return to the nursing home, and does not wish to burden or live with his children. He insists that he is not hungry and refuses assistance with his meal. He requests no visitors at this time, but later asks for his family to be called to discuss a plan of care.
You respond to Mr. Wiggins call light. He is complaining that his headache is worsening. You tell the pt that you must do a assessment before you can give him any medication. his Glasgow coma scale is 15. his VS are BP 168/80, T 98.9, P 98, R 24. Complete the neurological assessment.
Your neurological assessment concludes the following: A/O x4 appears normal, left pupil is slightly larger than his right and is +3 to react to light, there is no evidence of any drainage, cranial checks are WNL, and extremity strength is slightly diminished. Glasgow coma scale is 13.
After sharing findings w/ the provider, he orders the following: 1. Contact radiology for a stat CT scan of the head. 2. Start a saline lock. #. Neurological checks q30 minutes. 4. Hold coding, administer Tylenol 1g 5. NPO
You accompany transport of Mr. Wiggins from radiology back to his room. You check his VS and they are: BP 185/75, P 58, R 28 and irregular, T 99.1, PaO2 98. His GCS is now 10. neuro check: A/O x2, left pupil is larger than his right and is +5 to react to light, their is no evidence of any drainage, cranial checks are all normal and pt is less cooperative for extremity strength assessment. Upon finishing the assessment, Mr. Wiggins experiences a generalized tonic/clinic seizure.
The HCP has heard from the radiologist that there is a sub Duran hematoma on the left side of the brain. Pt needs emergency neuro surgery in order to stop the b led and relieve the pressure on the brain. His GCS is now 7. Prepare the pt for emergency neuro surgery.
Mrs. Workman presented to the diabetes clinic and provided a 24-hr food recall. She was then sent to the lab for ordered lab tests. She is to notify the nurse upon return to the clinic from the lab. Pt has requested more information on her diabetes and states she does not understand why she "should be concerned" w/ blood glucose control in both the short and long term.
The nurse is providing information on nutrition to assist Mrs. Workman in managing her DM II.
Mrs. Workman presented to the Diabetes clinic for further evaluation of her diabetes, and lifestyle changes. She is planning on attending several of the classes that are being offered. Pt is requesting information on appropriate exercise programs. She has attendee the diabetic meal prep classes, but still struggles with her dx of diabetes.
Day 3 of hospitalization at 12:30, Mrs. Workman calls the RN and complains of cool clammy skin, anxious, weak, hungry but nauseous, and slightly confused. April 10, 1245, Blood glucose level is 40 mg/dL HCP has ordered 1.) hypoglycemia protocols for BG level < 60 mb/dL 2.) regular insulin SQ 20 unit for BG level > 160 mg/dL 3.) monitor BG levels q 4 hours and PRN 4.) IVF D5 0.45% NS at 125 mL/hr 5.) 1800 calorie ADA dietary and teach pt about diet changes
3 months later, Mrs. Workman has returned to the Diabetes clinic having lost 20 lbs and is requesting to stop taking the metformin (glucophage). HbA1C is 7.5%. She is also complaining of new onset diarrhea.
Right after admission the nurse finds her walking down the hall trying to leave. Redirect the pt back to her room.
Mrs. Barkley is becoming more adamant about leaving while her physical condition continues to deteriorate. Her temp is 100.8, BP 100/62, P 92, R 21, SpaO2 91. The nurse auscultation fine crackles in her lungs bilaterally, but her sputum is clear. She is oriented x3 but at times seems to be talking to someone in the room when no one is present. She told the nurse that she does not want a breathing tube, but her family has told the nurse by phone that they want every effort done to save her. She pulled out her IV and it will need to be restarted for her IV I pro dose that is due now. The nurse has another high acuity admission that has just arrived from the ER.
Ms. Barkley continues to deteriorate and is shouting for her family. She is disoriented and believes the nursing staff is trying to kill her. Her temp is 101.3, BP 98/58, P98, R22, and PaO2 86%. the PCT is requesting to be relieved as the pt keeps pulling at the PCT's mask to see who she is. The RN calls the attending provider requesting that Ms. Barkley be txf to ICU but there are no rooms available. Instead the RN is told to put the pt on telemetry and call RT for a CPAP trial.
The pt continues to be combative while attempting to initiated the CPAP trial. Healthcare provider has ordered Haldol in order to sedate the pt. VS are deteriorating, BP 90/58, P 116, R 28, PaO2 85%, T 102.0. Enter the room after taking VS.
Ms. Barkley requires emergency intubation, and the HCP on scene suggests that the pt did not want to be intubated. You, the RN, are concerned because the family asked for everything to be done and the pt never signed a DNR order. The pt has now been sedated, and RT is temporarily maintaining their saturation's w/ effective valve mask ventilation.
Perform hand hygiene
Re-assess BP and pulse. BP 190/110, P 86.
Evaluate pts understanding of medication and provide education
Administer the medication
Document on the MAR and education in the chart.
Retake VS (BP 110/70, P 94)
Instruct pt not to get out of bed w/o assistance
Perform comfort measures
Request CNA to remain w/ pt
Notify the HCP using SBAR
Pt Kenny Barrett is nauseated and complains of dizziness when he sits up.
Pt was admitted yesterday afternoon w/ HTN, BP 178/90, P 88. HTN was undiagnosed and was. Started on Atenolol 50mg, 1x/day. This is his second dose. IV 20g, left forearm, NS 125ml/hr
Current VS BP 110/70, P 94, pt is pale, dizzy and nauseated.
Request possible change in medication and more frequent VS checks
Take VS now and Q4 hrs
Maintain strict I&O's
500 mL NS bonus
Hold next dose of Atenolol if BP <130/80
Contact HCP if pt status does not improve
Assess stress level
Communicate w/ the pt therapeutically
Discuss willingness for alternatives to smoking
Educate pt as to why he cannot go outside and smoke
Contact HCP for Nicotine patch order
Don appropriate PPE
Change to simple O2 face mask per HCP
Perform focused respiratory assessment
Notify respiratory therapist to begin tx
Notify family to self-isolate for 14 days
Reorient pt to setting using therapeutic communication
Obtain a sitter/UAP
Restart the IV
Begin strict I&O
Obtain an order to insert a Foley catheter
Use therapeutic communication to explain necessary procedure.
Position the pt properly
Create sterile field w/ foley kit on the bedside table and don sterile gloves.
Instruct Lucy to assist in maintaining pt position and field sterility
Insert Foley catheter according to hospital recommended guidelines, to ensure sterility of catheter.
Make sure O2 mask is secure and free of sputum.
Ensure pt is in Fowler's position
Check the Foley catheter to make sure it is not obstructed
Provide initial report and assist RRT
Mr. Raymond, COVID-19 positive, in severe respiratory distress, RRT called
Pt has a hx of COPD, HTN, DM II, and a recent MI. Pt received furosemide Lasix 20mg, IVP x2, on Claforan Q4, and on sliding scale insulin.
Intubated by RRT, BP 88/58, P 110, T 101.2, SaO2 94%, ABG's are pending, F/C in place.
Recommend pt be txf to ICU
Accompany pt to ICU and give report to receiving RN
Mr. Lyles calls you via the call light. Upon entering the room, he asks if you have medication for "heartburn". He says, "I take TUMS at home when this happens." You tell the pt you will be glad to check-on what is available for relief of his "heartburn" after you complete his physical assessment. You begin his assessment, and he falls back in the bed and becomes unresponsive. You shouldn't, "Are you okay? Are you okay?"
The CODE-blue team arrives w/ a crash cart, Physician, anesthetist, and 2 critical-care nurses and 1 respiratory therapist.
You have now been assigned to document the ongoing event as the CODE team continues w/ the resuscitation.
After 15 minutes, the pts rhythm returns, but he is still unresponsive. He is now in V-tach w/ a weak pulse and BP 70/40. Prepare to initiate cardioversion.
Mr. Lyles responded to the first cardioversion, and is now in a sinus-Brady w/ a second-degree heart block. He is still unresponsive. VS are BP 80/40, P 46, R 16, (pt now intubated and ventilated by Respiratory Therapy)
Mrs. Smith shares w/ you that even though she signed the operative consent she was not sure if this was the right surgical procedure for her. Her husband who is present stats, "I thought it was just a lumpectomy she was having this morning."
It is now 2 wks later; Mrs. Smith has returned. You question her while reviewing her operative consent and determine that everything is correct. She receives the pre-op medication. Her husband and children remain w/ her in the surgical holding area awaiting transport to the OR.
Mrs. Smith's surgery has now ended. You now arrive in the recovery unit one hour post-surgery and you are told that the surgery went well. Her chart reports she was exhibited upon arrival to the recovery area, received three units (3000 mL) of fluid, receiving O2 @ 4LNC, F/C in place draining QS clear yellow urine, responds to verbal stimuli, chest dressing in place remains dry and intact, and has just received a small dose of IV morphine for pain. VS are BP 112/78, T 97.4, R 16, and O2 94%.
You are about to call the Surgical ICU and give report. What order are you providing the information to the receiving nurse?
You are now the Surgical ICU nurse assigned to her. She has just been transported from recovery. List the nursing care order.
Pt presents to the unit c/o numbness in the rt foot and ankle and toes "not looking the right color". All 5 toes on the right foot are necrotic, absent pedal pulses, skin cold to touch, appearance dry, cracked and black up to mid-calf. Foul odor noted w/ green drainage coming from toenail beds. Doctor orders 1.) IVF 0.9% NS peripheral line @ 100mL/hr 2.) CBC, CMP, Blood culture x 2, Hgb A1C 3.) CT scan of rt lower leg 4.) Blood lab tests 5.) Levofloxacin (Levaquin) 750 mg IV q 24hrs
Pt speaking incoherently and is exhibiting rapid eye movement w/ a blank stare. An empty syringe is noted in the bed. Pt does respond partially to commands. Brisk peripheral reflexes, eyes equal, round, dilated
8 hrs later, pt is fidgety and is observed picking at her skin and clothes. The pt states, "I am sick to my stomach and feel like I have bugs crawling all over me!!!"
Surgery called to the unit the Ms. Pittman is scheduled at 1300 for a BKA.
Post op day 3 time for dressing change stump. Pt sates pain has been managed through the night. Pulses above the stump are palpable at 2+, skin is warm and dry. Pt states she has noted some "toe pain" but that it has been <3 on a scale of 1-10.
Pt is scheduled for and ECG and MRI this AM. You are entering the room for the first time. After performing handy hygiene and introducing yourself to pt, you should...
The dx tests were completed and Dr. Gray has informed the pt of the dx of HF and tx w/ digoxin. Upon entering the room, the pt is crying and asks when will the medication fix her heart.
A few days later, you are assigned to the same pt. She receives her AM medications including levothyroxie, diltiazem and digoxin. After your AM assessment, the pt's call light goes on and she is complaining of nause, abd pain, and seeing "yellow circles". Upon entering the room, the pt is standing by the bed...
The labs return w/ digoxin level of 10.5 ng/mL, K 5.3 mEq/L. Other labs were WNL. HCP orders digoxin immune fab to be given.
Four hours later, the telemetry tech calls and states the pt is Sinus Tach 102 w/ occasional multi focal PVC's, pt is complaining of cramping in her legs. Her last K was 3.2 mEq/L. She appears short of breath when talking.
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