Clinical 2

Educational Needs Increased acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Increased acuity Psychological Needs Normal acuity Sensorium Normal acuity

Physiological Bleeding, Risk for True Constipation False Deficient Fluid Volume, Risk for True Dysfunctional Gastrointestinal Motility False Imbalanced Fluid Volume False Impaired Mobility True Safety Anxiety False Fall, Risk for True Ineffective Self-Health Management False Infection, Risk for True

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

Educational Needs Increased acuity Fall Risk Normal acuity Health Change Increased acuity Pain Level Increased acuity Psychological Needs Increased acuity Sensorium Normal acuity

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 Esteem Decisional Conflict False Ineffective Coping True Noncompliance False Rape-Trauma Syndrome True Self-actualization Disturbed Energy Field True Spiritual Distress False

Scenario 1 Use therapeutic communication/Active Listening Full Assessment Provide emotional support Documentation Scenario 2 Use therapeutic communication/Active Listening Educate patient Provide supplies and needed instructions. Offer to Assist Scenario 3 Use therapeutic communication/Active Listening Ask open-ended questions Seek clarification Summarize discussion Scenario 4 Restate or paraphrase patient statements Acknowledge patient's decision Review plan of action Notify social services Document process Scenario 5 Review Labs Educate Patient-STD's and pregnancy Provide emotional support Discuss Support Groups

Educational Needs Increased acuity Fall Risk Increased Acuity Health Change Increased Acuity Pain Level Increased Acuity Psychological Needs Normal Acuity Sensorium Normal Acuity

Physiological Activity Intolerance False Acute Pain True Diarrhea False Electrolyte Imbalance, Risk for True Impaired Comfort True Impaired Mobility False Safety Deficient Knowledge True Fall, Risk for True Fear False Ineffective Self-Health Management False Infection, Risk for True Sleep Deprivation False

Senario 1 Introduce Yourself/Identify Patient Full Assessment Educate Patient Evaluate Understanding Provide Comfort Senario 2 Wash/Glove Hands Inspect Pain Location Check Proper Positioning Verify Call Light/Bed Safety precautions Notify Doctor (for possible Removal) Senario 3 Educate patient of procedure Evaluate Understanding Remove NG-Tube Administer Diet Order Document Results Senario 4 Wash/Glove hands full assessment encourage incentive spirometry Verify call light/bed safety precautions Document Results Senario 5 Use therapeutic communication/active listening Educate patient Evaluate Understanding Verify call light.bed safety Document results

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 Bleeding, Risk for True Constipation False Impaired Mobility True Impaired Skin Integrity, False Ineffective Peripheral Tissue Perfusion False Safety Acute Confusion False Deficient Knowledge False Fall, Risk for True Ineffective Self-Health Management True Infection, Risk for True Peripheral Neurovascular Dysfunction False

Senario 1 Assess for bowel sounds Administer PRN constipation medications Encourage fluids and fiber diet Evaluate understanding Review pain medication order Senario 2 Check physician orders Educate patient Offer bedpan Record intake and output Verify call light/bed safety precautions Senario 3 Obtain vital signs machine Wash and glove hands Identify patient Assess vital results Document results and findings Senario 4 Wash and glove hands Administer antipyretic medication Encourage fluids Notify doctor Document results and findings Senario 5 Notify Physical Therapy (PT) PT to educate patient Read PT report Re-assess patient Evaluate/Modify Mobility Plan

Educational Needs Increased acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Normal acuity Psychological Needs Increased acuity Sensorium Normal acuity

Physiological Dysfunctional Gastrointestinal Motility False Electrolyte Imbalance False Fatigue True Impaired Gas Exchange True Impaired Mobility False Ineffective Airway Clearance True Safety Anxiety True Deficient Knowledge True Fall, Risk for False Fear True Hypothermia False Impaired Home Maintenance Management False Love and belonging Chronic Sorrow False Social Isolation, Risk for True Esteem Decisional Conflict False Noncompliance True Self-Actualization Readiness for Self-Care Enhancement True Spiritual Distress False

Scenario 1 Don Personal Protective Equipment Allow for non-compliance of request Do not probe further Verify call Light/bed safety precautions Document results Scenario 2 Obtain translator Offer masks to visitors Educate patient Evaluate understanding Obtain Spanish signs & brochure Scenario 3 Obtain translatorT Wash and glove hands Gown and mask Administer antipyretic medication Encourage fluids Scenario 4 Educate caller regarding HIPAA Evaluate caller understanding Refer call to contact health department Notify doctor Document conversation Scenario 5 Obtain translator Use therapeutic communication/Active Listening Educate patient Evaluate learning Document teaching moment

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

Senario 1 Wash and glove hands Vital assessment Administer pain medications Re-assess patient Document results Senario 2 Vital Assessment Notify Doctor for pain medz Administer new pain medz Re-assess patient Senario 3 Use therapeutic communication/Active Listening Obtain urinary screen Assist patient Remain with patient Document results and findings Senario 4 Use therapeutic communication/Active Listening Educate patient Evaluate understanding Contact dietary consult Document results Senario 5 Discharge instructions Evaluate understanding Escort patient to vehicle Document results Notify housekeeping

Educational Needs Increased acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Increased acuity Psychological Needs Normal acuity Sensorium Normal acuity

Physiological Deficient Fluid Volume True Electrolyte Imbalance, Risk for True Excess Fluid Volume, Risk for False Fatigue True Nausea False Self-Care Deficit False Safety Fall, Risk for True Infection, Risk for False Esteem Ineffective Coping False Noncompliance True

Scenario 1 Assess intake and output and possible reasoning Construct dietary consult (plan) Acquire daily weight and food intake Evaluate outcome of dietary plan Scenario 2 Full assessment including both lying/standing Check input/output for possible dehydration Teach patient about safety when getting out of bed Document findings Scenario 3 Wash and glove hands Provide emesis basin/cloth Vital assessment Administer antiemetic medication Evaluate medication effectiveness Scenario 4 Vital assessment Assessment of bowel movement Administer protocol antidiarrheal medication Document results/findings Include patient condition change in shift report Scenario 5 Inform and educate spouse of dietary orders Evaluate/modify plan of care Assess food consumption and intake and output Document findings/results

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 Bleeding, Risk for False Chronic Pain False Impaired Comfort True Impaired Mobility True Nausea False Safety Deficient Knowledge False Disturbed Sensory Perception True Fall, Risk for True Grieving False Infection, Risk for False Peripheral Neurovascular Dysfunction True

Scenario 1 Use therapeutic communication/Active Listening Educate patient regarding patient care Evaluate patient learning Place call light and check bed for safety Document results and findings Scenario 2 Wash and glove hands Assess Provide comfort measures Notify doctor Document results and findings Scenario 3 Listen to patient concerns Reassure patient of options Notify lead nurse/doctor Contact Social Services Document results Scenario 4 Wash and glove hands Visual assessment Do not disturb Verify Call Light/Bed Safety precautions Document results Scenario 5 Assess for bowel sounds Encourage fluids/fiber/ambulation Evaluate patient understanding Attain fluids/fiber diet and assisted ambulation Document results

Educational Needs Increased acuity Health Change Increased acuity LOC Normal acuity Pain Level Increased acuity Safety Increased acuity

Physiological Acute Pain True Bleeding False Chronic Pain False Constipation False Knowledge Deficit True Nutrition True Risk for Infection True Skin integrity at risk True Love and Belonging Compromised Family Coping False Fear/Anxiety True

Scenario 1 Perform full assessment and provide anti-nausea medicine. Provide comfort in pre-surgical room Mr. Dominec. Check surgical consent for correct procedure and make sure operative site in marked. Inform his partner that everything is being done to keep him comfortable. Scenario 2 Educate about recovery from appendectomy and care to wound. Discuss his understanding about the plan of care. Discuss follow up with his doctor. Offer assistance in providing more information about treatment options for newly diagnosed AIDS patients. Determine from medical record if partner is aware of his recent AIDS diagnosis. Scenario 3 You discuss this cough with Mr. Dominec to determine how long he has had it. Notify doctor of change in condition in particular: unproductive cough and low-grade fever. Explain to Mr. Dominec your concern for this opportunistic infection and usual treatment. Explain that he will probably not be going home at least until his doctor sees him. Notify charge nurse that discharge will probably not occur today. Scenario 4 Inform patient about the progression and risk a PCP infection has for a patient with AIDS. Obtain and provide the infectious disease doctor's contact information for him. Encourage Mr. Dominec to discuss with his partner his best treatment options. Take vital signs before leaving the hospital again. Document and provide copy for Mr. Dominec to share with his follow up appointment tomorrow. Scenario 5 This information is HIPAA protected and you cannot share anything with them. Remind staff that Universal Precautions are practiced at this hospital for all patients regardless of known infectious diseases. Leave to break room and not continue in conversation. Report this activity immediately to the hospital privacy officer Report to charge nurse/ head nurse the need for staff education.

Educational Needs Increased acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Increased acuity Psychological Needs Increased acuity Sensorium Normal acuity

Physiological Acute Pain True Chronic Pain False Impaired Mobility True Impaired Skin Integrity, Risk for True Ineffective Peripheral Tissue Perfusion False Self-Care Deficit False Safety Anxiety True Deficient Knowledge True Fall, Risk for True Grieving False Impaired Home Maintenance Management r/t Client or Family False Peripheral Neurovascular Dysfunction False Esteem Decisional Conflict True Deficient Diversional Activity False Disturbed Body True Hopelessness False

Scenario 1 Check pedal capillary refill Educate patient Evaluate understanding Adjust crutches Assist patient out of bed Scenario 2 Wash and glove hands Vital assessment Administer antipyretic meds Verify call light/bed safety precautions Document results/findings Scenario 3 Inspect cast site Assess toe movement and capillary refilling Notify doctor if condition is abnormal Document Results/Findings Scenario 4 Elevate Extremity Assess pain Educate patient regarding condition Notify lead nurse/doctor Retrieve cast removal tool Scenario 5 Use therapeutic communication/Active Listening Notify lead nurse/doctor Consult Social Service Evaluation patient after consult Document Results

Educational Needs Increased acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Increased acuity Psychological Needs Increased acuity Sensorium Normal acuity

Physiological Bleeding, Risk for False Chronic Pain True Constipation, Risk for True Decreased Cardio Tissue Perfusion False Imbalanced Nutrition True Impaired Skin Integrity False Safety Anxiety True Deficient Knowledge False Fear True Grieving True Impaired Home Maintenance management r/t client or family False Ineffective Self-Health Management False Esteem Disturbed body False Hopelessness True Noncompliance False Powerlessness True

Senario 1 Wash and glove hands Full assessment Seek clarification Check PRN pain order Verify call light/bed safety precautions Senario 2 Full assessment Educate patient regarding changes to POC Place patient on PCA pump Observe closely first hour Perform pain re-assessment Senario 3 Use therapeutic communication/active listening Educate patient/family Notify doctor Contact Social Services Report and document results Senario 4 Use therapeutic communication/Active Listening Notify doctor for Foley catheter Education of Foley Cath Procedure Insert Foley catheter Document Procedure Senario 5 Allow family to remain Full assessment Provide comfort and pain measures Pain re-assessment Document results

Educational Needs Increased acuity Health Change Increased acuity LOC Increased acuity Pain Level Increased acuity Psychological Needs Normal acuity Safety Increased acuity

Physiological At Risk, Impaired Comfort False Impaired Gas Exchange True Ineffective airway clearance True Shock False Safety Chronic Confusion False Love and Belonging ExplanationAnxiety/ fear True Failure to Thrive False

Scenario 1 Replace oxygen nasal cannula that had become disconnected Therapeutic communication Assess Notify doctor and charge nurse Scenario 2 Remind physician to wash his hands before examining the patient Explain to physician what interventions you have recently initiated Assist physician in physical exam of patient Obtain recent chest X-ray reports and recent ABG's for physician to review Reassure patient and help explain any new orders from physician to patient Scenario 3 Tap patient and ask, "Are you okay?" Elevate head of bed Call Rapid Response protocol initiated Start secondary large bore IV line Remain with patient and reassure Scenario 4 Provide verbal report to team members who respond to rapid response Emergency intubation and assisted breathing is provided for Mr. Thomason Assume role in response team of documenter Obtain patient record and follow patient as he is transferred to ICU Provide information for MD to call family at home and explain what has just happened Scenario 5 You explain that his condition has worsened and now he has been taken to ICU. You explain that he is receiving a higher level of care and was he was sedated before leaving the floor to make him more comfortable. You have them remain with you, seated in comfortable place, while you call ICU and attempt to locate physician for them. You escort them with you to the ICU. You call his doctor to inform him the family has arrived.

Educational Needs Increased acuity Health Change Increased acuity LOC Normal acuity Pain Level Increased acuity Psychological Needs Normal acuity Safety Increased acuity

Physiological Bleeding False Impaired Gas Exchange False Ineffective breathing pattern False Pain, Acute True Physical Mobility, Impaired True Skin integrity, impaired True Safety Acute Confusion False Knowledge Deficit True Esteem Disturbed Body Image True Hopelessness False

Scenario 1 Ask patient to explain to you what procedure she was expecting to have this morning. If patient statement differs from the surgical consent she has signed, notify surgeon immediately Stay with patient for surgeon's arrival to explain intended surgical procedure Contact head nurse or supervisor in the OR to evaluate new situation Procedure is canceled for the day and rescheduled later allowing for new consent. Scenario 2 Therapeutic communicationT Validate NPO Status Encourage to ambulate with assistance to void if needed Connect telemetry Provide a few chairs if possible for her family to also be comfortable Scenario 3 Vital signs taken by automatic B/P Cuff q 15 minutes Assess Talk with her stating surgery is over and she did great. Allow husband to come into recovery for a quick one-minute visit. Document and prepare to transfer to Surgical ICU Scenario 4 Provide Operative summary of type of procedure, IV fluid and pain status. Present health assessment including B/P and LOC and dressing. Report current urinary output quantify per hour and color of urine Request time she can arrive and staff to help with transfer Explain to her family and provide contact information. Scenario 5 Full assessment of patient. Provide for physical and thermal comfort. Therapeutic communication. Begin post op education for day one Notify family as to when they may come and visit.

Educational Needs Increased acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Increased acuity Psychological Needs Increased acuity Sensorium Increased acuit

Physiological Bleeding, Risk for True Decreased Cardiac/perfusion False Imbalanced Nutrition True Nausea False Self-Care Deficit True Shock, Risk for False Safety Acute Confusion True Fall, risk for True Peripheral Neurovascular Dysfunction False Sleep deprivation False Love and belonging Compromised Family Coping False Failure to Thrive True

Scenario 1 Perform neuro assess Reorient Patient to person, place, & time Assess for fall risk Offer nutrition/toilet Scenario 2 Explain reason for assessment and procedure Vital sign assessments Apply restraint Perform circulatory evaluation Request sitter/family member to bedside Scenario 3 Employ therapeutic communication: present reality Release restraints/full range of motion Reapply restraints Perform circulatory evaluation Document results Scenario 4 Use therapeutic communication/active listening Attempt to orient to person, place, and time Perform circulatory evaluation Offer nutrition and/ or toileting Document results Scenario 5 Check monitor Apply nasal cannula Vital re-assessment Notify lead nurse/doctor Remain with Patient

Educational Needs Increased acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Normal acuity Psychological Needs Increased acuity Sensorium Increased acuity

Physiological Acute Pain False Deficient Fluid Volume False Electrolyte Imbalance True Imbalanced Fluid Volume, Risk for True Impaired Skin Integrity, Risk for False Ineffective Renal Perfusion, Risk for True Safety Acute Confusion True Disturbed Sensory Perception False Fall, Risk for True Sleep Deprivation False Love and belonging Anxiety False Failure to Thrive True

Scenario 1 Wash and glove hands Full assessment Monitor and evaluate fluid intake Educate patient Document results Scenario 2 Wash and glove hands Full assessment Apply fall risk bracelet Document results Scenario 3 Offer assistance Remain with patient Therapeutic Communication Notify lead nurse Document results Scenario 4 Visual assess Call rapid response Apply oxygen Establish second IV Remain with patient Scenario 5 Give verbal report Escort patient Notify family Document results