SR Meds Surg - Nursing Process

Arthur Thomason, 56-year-old MVA victim, fourth day post op with a splenectomy and femur repair. He is experiencing new onset of shortness of breath and has a nasal cannula with 2L of Oxygen in place. He is restless with slight confusion but is easily orientated with attempts from nurse. Temperature spiked during the night to 102.4, BP now 146/94 which is slightly elevated, respirations at 30 bpm and slightly labored, heart rate 102 versus 84 from last night shift. Skin cool to touch and appears pale. His coughing, to clear his airway, appears ineffective. Recent chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes. Recent blood gases demonstrate falling PaO2 (hypoxemia) and increasing CO2 (Hypercapnia). Mr. Thomason is anxious and is obviously worsened from the shift before in overall condition.

Arthur Thomason

A.T. Scenario 1

A.T. Thomason Scenario 2

A.T. Scenario 3

A.T. Scenario 4

A.T. Scenario 5

Charlie Raymond, 65-year-old male who was admitted to a negative pressure room on Med-Surg for COVID precautions.. He has a history of COPD, hypertension, diabetes type II, and a recent myocardial infarction. He is a retired postal worker who lives at home with his wife. He is on Claforan (cefotaxime) 2 g IV q4hr and sliding scale insulin. Initially this cardiologist was concerned about congestive heart failure and Mr. Raymond is receiving Furosemide (Lasix) 20 mg IV twice a day for pulmonary edema. Vital Signs: BP is 145/78, Pulse 89 Respirations 24 and slightly labored, Temperature 100.2 SaO2 94% on 2L nasal cannula. The patient/family is fearing the worst due to COVID-19 Pandemic.

Charlie Raymond 65-year-old male who was admitted to a negative pressure room on Med-Surg for COVID precautions.. He has a history of COPD, hypertension, diabetes type II, and a recent myocardial infarction. He is a retired postal worker who lives at home with his wife. He is on Claforan (cefotaxime) 2 g IV q4hr and sliding scale insulin. Initially this cardiologist was concerned about congestive heart failure and Mr. Raymond is receiving Furosemide (Lasix) 20 mg IV twice a day for pulmonary edema. Vital Signs: BP is 145/78, Pulse 89 Respirations 24 and slightly labored, Temperature 100.2 SaO2 94% on 2L nasal cannula. The patient/family is fearing the worst due to COVID-19 Pandemic

Charlie Raymond Scenario 1 The next day, he tests positive for COVID 19 and his condition has deteriorated as he is now in respiratory distress. Mr. Raymond weighs 260 lbs. Vital Signs: BP is 92/58, Pulse 102, Respirations 30 and labored, Temperature 101.3, SaO2 91% . He has bilateral lower lobe atelectasis with bronchial/vesicular wheezing.

Charlie Raymond Scenario 2 Mr. Raymond continues to deteriorate and becomes confused. In his confusion, he becomes combative and pulls out his IV. He is on a 100% nonrebreather and he keeps pulling his mask off. Just received an order to initiate 20 mg of Furosemide (Lasix) IVP, BID.

Charlie Raymond Scenario 3 Order for a foley catheter has been obtained and Lucy Jones, LPN, is there to assist. Both nurses have donned appropriate PPE and have entered the room.

Charlie Raymond Scenario 4 UAP reports urinary output of 50 mL over the past three hours. Repeat focused pulmonary assessment reveals profound bilateral atelectasis in the bases and frothy white sputum. Increased Respiratory rate of 32 and labored, peripheral edema +3 in both ankles and JVD. Based on findings, nursing care actions that are most concerning are:

Charlie Raymond Scenario 5 Mr. Raymond is stabilized with RRT. Give an SBAR to Hospitalist:

Donald Lyles Room 301 Donald Lyles, 52-year old male, was admitted yesterday evening for stabilization of his uncontrolled type II diabetes. He is married, and his wife is requesting to stay at his side. His HbgA1c is 10.6%. He has a history of a Myocardial Infarction, MI, one year ago, and has refused all cardiac rehab, and has not had another cardiac event. He refuses to comply with dietary recommendations. His BMI is 37. Vital signs are: BP: 146/94, P: 88, R: 22, T: 99.2, PaO2: 94% Blood glucose upon admission is 340 mg/dl

Donald Lyles 52-year old male, was admitted yesterday evening for stabilization of his uncontrolled type II diabetes. He is married, and his wife is requesting to stay at his side. His HbgA1c is 10.6%. He has a history of a Myocardial Infarction, MI, one year ago, and has refused all cardiac rehab, and has not had another cardiac event. He refuses to comply with dietary recommendations. His BMI is 37. Vital signs are: BP: 146/94, P: 88, R: 22, T: 99.2, PaO2: 94% Blood glucose upon admission is 340 mg/dl

Donald Lyles Scenario 1 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 patient 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 shout, "Are you okay? Are you okay?"

Donald Lyles Scenario 2 The CODE-blue team arrives with a crash cart, Physician, Anesthetist, and 2 critical-care nurses, and 1 Respiratory therapist.

Donald Lyles Scenario 3 You have now been assigned to document the ongoing event as the CODE team continues with the resuscitation.

Donald Lyles Scenario 4 After 15 minutes, the patients rhythm returns, but he is still unresponsive. He is now in Ventricular tachycardia with a weak pulse, and a BP of 70/40. Prepare to initiate Cardio-version.

Donald Lyles Scenario 5 Mr. Lyles responded to the first cardioversion, and is now in sinus-bradycardia with a second-degree heart block. He is still unresponsive. Vital signs are BP:80/40, P: 46, R:16 (patient now intubated, and ventilated by Respiratory Therapy).

Dotty Hamilton, 52 y/o female who has been admitted for bariatric Surgery. She has arrived at 0600, and is scheduled for a laparoscopic Roux-en-Y gastric bypass (RYGB). She is super morbidly obese with a BMI of 52, Ht, 5'3", Wt, 293lbs. She has well controlled hypertension with Losartan (Cozaar) 50 mg q daily. She also takes Metformin to control her Type 2 Diabetes. She has sleep apnea, and she brought her CPAP machine. She is very excited about the surgery but is also apprehensive. She was told by a friend that the complication rate for this surgery is very high. She believes this surgery is her only hope, as she says she has tried everything else to lose weight. Her husband is with her and seems to be very supportive. Body Mass Index (BMI) = kg/m2 where kg is a person's weight in kilograms and m2 is their height in metres squared. A BMI of 25.0 or more is overweight, while the healthy range is 18.5 to 24.9. Example: Weight = 133.18 kg, Height = 160.02 cm (1.60 m) Calculation: 133.18 ÷ (1.60)2 = 52

52 y/o female who has been admitted for bariatric Surgery. She has arrived at 0600, and is scheduled for a laparoscopic Roux-en-Y gastric bypass (RYGB). She is super morbidly obese with a BMI of 52, Ht, 5'3", Wt, 293lbs. She has well controlled hypertension with Losartan (Cozaar) 50 mg q daily. She also takes Metformin to control her Type 2 Diabetes. She has sleep apnea, and she brought her CPAP machine. She is very excited about the surgery but is also apprehensive. She was told by a friend that the complication rate for this surgery is very high. She believes this surgery is her only hope, as she says she has tried everything else to lose weight. Her husband is with her and seems to be very supportive. Body Mass Index (BMI) = kg/m2 where kg is a person's weight in kilograms and m2 is their height in metres squared. A BMI of 25.0 or more is overweight, while the healthy range is 18.5 to 24.9. Example: Weight = 133.18 kg, Height = 160.02 cm (1.60 m) Calculation: 133.18 ÷ (1.60)2 = 52

Dotty Hamilton Scenario 1 Dotty Hamilton is being prepared for surgery. Her VS are P 92, BP 142/80, R 20, Temp 99.1 F, 37.6 C, PaO2 98. Her blood glucose is 92, and she tells the nurse she has been taking her metformin. The nurse reports to the surgeon that her metformin was not held preoperatively. The nurse reviews her labs prior to surgery, and they are: H/H 15/42, Platelets 200,000. Na 139 mEq/L, K 3.8 mEq/L, Ca 4 mEq/L, Mg 3 mEq/L, Cl 97 mEq/L. Bun 0.2 mg/dl, Creatinine 0.9 mg/dl. Her liver function test were not done in the pre-op clinic so the nurse sent off a stat panel and just got the results back: Bilirubin 1.7, ALT 32 U/L, AST 22 U/L, GGT 61 U/L, ALP 98 U/L. The nurse reports to the surgeon and the nurse receiving the patient in the pre-op hold that all her lab results have been reported along with her morning BG finger stick. She also received all her PO morning meds with a sip of water at 0600.

Dotty Hamilton Scenario 2 After returning from surgery, her recovery is uneventful. Patients BG is elevated to 168, and the nurse was told that the patient received Decadron for N/V by anesthesia. The surgeon thanked the nurse for letting him know of the elevated Liver enzymes. It was discovered during surgery that her gallbladder was inflamed, and the decision was made to remove her gallbladder. She is being medicated with Fentanyl 25 mcg IVP for pain, and the patient is running a low grade temperature 99.7 F, 37.6 C. Your initial steps of care:

Dotty Hamilton Scenario 3 Post-operative day 2, Dotty Hamilton's fever continues to rise, as well as her BG that are now in the 300s. Patient is pale and diaphoretic. She has insulin ordered as well as antibiotics. Her VS are BP: 120/90, T: 100.5 F, 38.1 C, R: 24, P: 92 She is complaining of increased abdominal pain, and is maxed out on the pain medication as ordered. Her husband is concerned. She has been placed on a Dilaudid (Hydromorphone) PCA pump. The nurse alerts the Healthcare Provider of her concern for the increased pain. She believes the pain may be a result of surgical complications.

Dotty Hamilton Scenario 4 During the night Dotty Hamilton becomes very anxious, she says something is just not right. She calls her husband who is also very concerned. The night nurse tries to comfort the patient, and reassures her that she is fine. Her VS are P 110, BP 110/62, R 25, PaO2 94, and Temp 101.6 F, 38.7 C. She also complains that her IV is burning, so the nurse holds her antibiotics until another IV can be started. Patients last IV had to be started by anesthesia. Patients urinary output in the last 4 hours has only been 30 mL. The nurse is concerned that the patient is becoming septic. Surgery on call has ordered stat labs, to include blood cultures and a 1000 mL bolus lactated ringers.

Dotty Hamilton Scenario 5 Post op day 3, Dotty Hamilton's condition continues to deteriorate; the Health care provider is on their way. She is having difficulty breathing and maintaining her Oxygen saturation. She is placed on 100% non-rebreather, but prior to that an ABG is drawn, as well as STAT labs to include lactate. Her ABG results shows hypoxia, and she appears to be in lactic acidosis, (PH 7.33, PaCO2 25, PaO2 79, HcO3 12, Lactate 28 mg/dl). It is determined that she needs to be transferred to the ICU for more aggressive care and possible intubation, but there are no beds available at this time. Anesthesia determines it is best that patient have a central line as her peripheral IV patency is too difficult to access.