Swift River Medical-Surgical

Educational - Increased Fall Risk - Increased Health Change - Increased Pain - Increased Psychological Needs - Normal Sensorium - Normal

Acute pain Impaired comfort Impaired mobility Disturbed sensory perception Fall, risk for Peripheral neurovascular dysfunction

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

Educational - increased Health change - increased LOC - increased Pain - increased Psychological needs - increased Safety - increased

Impaired confort Impaired gas exchange Ineffective airway clearance Shock, risk for Anxiety/fear Failure to thrive, risk for

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

Educational - increased Fall Risk - normal Health Change - increased Pain - increased Psychological needs - normal Neurological - normal

Acute pain Deficient knowledge

Scenario #1 Place on respiratory isolation Ask Mr. U Obtain blood cultures Start IV Collect sputum culture Scenario#2 Wash hand, don PPE Explain to the visitor Respiratory assessment Explain to Mr. U Place signage on door Scenario #3 Ask pt. what he knows Ask pt. what his mother's Educate pt. Evaluate effectiveness Report findings Scenario #4 Pt. teaching Contact respiratory therapy Chest x-ray Western blot Bronchoscopy Scenario #5 Elevate HOB Initiate O2 at 4L Reassess VS Reevaluate amount of blood lost Contact HCP

Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - normal Neurological - normal

Acute pain Impaired mobility Deficient knowledge Fall, risk for Infection, risk for

Scenario #1 Give tylenol Start another IV Initiate bolus Request additional pain med Reasses temp in 1 hour Scenario #2 Sit at an eye level Teach Cameron Evaluate understanding Contact charge nurse Document pt's statements Scenario #3 Provide emotional support Assure pt. Explain to pt. Stress importance Inform pt. Scenario #4 Make sure accurate wt. Explain reason for medication Tell the mother that you understand Tell the mother that visitors are welcome Be honest with Cameron Scenario #5 Assess pt. Perform rapid assessment Ask pt. Inform charge nurse Call local law enforcement

Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Neurological - normal

Acute pain Impaired mobility, risk for Nausea Cultural competence Deficient knowledge Impaired verbal communication

Scenario #1 Obtain translator Initiate IV Begin fluid and electrolyte Administer IV ABX Consult with MD Scenario #2 What is going on? We need to stop the bleeding Tell me where you are Who were you talking to? What were the voices telling you? Scenario #3 Attempt to establish rapport Notify HCP of findings Attempt to restart IV Contact dietary Obtain a sitter Remove potential harmful objects Scenario #4 Delay insertion of IV Contact HCP Contact CC's uncle Request the uncle come Request the uncle participates Scenario #5 Provide one-to-one Initiate anti-psychotic meds Ensure family member Reassess environment Initiate continuous observation

Educational - increased Fall Risk - increased Health Change - increased Neurological - normal Pain - increased Psychological needs - normal

Acute pain Impaired mobility, risk for Fluid & electrolyte imbalance, risk for Infection

Scenario #1 Contact isolation Administer pain meds Initiate IV Ask pt. Document physical findings Scenario #2 Explain the need Elevate HOB Measure nose to ear Have pt. swallow Check placement Scenario #3 Remind pt. Reassess pt. Obtain an order Teach pt. to avoid Teach pt. to apply Scenario #4 Assess pain Asminister morphine NG tube to LIS Call for triple lumen Address concerns Scenario #5 Therapeutic communication Pt. teaching Evaluate learning Make referral Dietary consult

Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - normal Neurological - normal

Deficient knowledge Grieving, risk for

Scenario #1 Sit with the pt. Reinforce provider teaching Assess family support system Reassure the pt. Ask the pt. Scenario #2 Head-to-toe assessment Inspect catheter Teach pt. Instruct pt. Ask the charge nurse Scenario #3 Teach the pt. Explain to the pt. Administer pain meds Tell the pt. Have the pt. ambulate Scenario #4 Inspect pt's abdomen Auscultate Percuss & palpate Contact provider Tell husband & pt. Scenario #5 Inform the pt. Provide pt. privacy Lubricate tip of enema Squeeze the contents Have the pt. lay on their side

Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Neurological - normal

Acute pain Altered body image, risk for Audiology changes, risk for Fluid & electrolyte imbalance, risk for PTSD, risk for Infection, risk for

Scenario #1 Complete full assessment Insert foley Initiate IV Apply Silvadene Contact HCP Scenario #2 Reassess lung sounds Empty foley bag Administer pain meds Notify HCP Document Scenario #3 Elevate HOB Assess pt's sputum Reassure the pt. Assure the pt. Contact respiratory therapy Scenario #4 Obtain doppler pulse Adjust rate of IV Ask for available tech Change dressing Determine if the pt. Scenario #5 Obtain bear hugger Explain to the pt. Notify nursing supervisor Contact nutritionist Allow visitors to enter

Educational - increased Fall Risk - normal Health Change - normal Pain - normal Psychological Needs - increased Neurological - normal

Bleeding, risk for Impaired comfort, risk for Deficient knowledge Infection, risk for

Scenario #1 Contact surgeon Complete pre-op Ensure surgical consents Check to see Pt. teaching Scenario #2 Wash hands Complete full assessment Check wound sites Use therapeutic Encourage first IS Scenario #3 Reassure & communicate Check blood glucose Administer ABX Encourage aggressive IS Start PCA pump Scenario #4 Reassure pt. Complete full pt. assessment Assess whether or not Obtain labs Notify HCP Scenario #5 Complete full assessment Place pt. on telemetry Check foley Assist anesthesia Explain to pt. Scenario #6 Have family step out Bring the family in Offer to the family Contact funeral home Ask nursing manager

Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - normal Neurological - normal

Acute pain Impaired mobility, risk for Nausea, risk for Deficient knowledge

Scenario #1 Ensure room was cleaned Disinfect call light Clean and obtain IV pole Obtain burn sheets Notify infection control nurse Scenario #2 Obtain VS Initial assessment Administer pain meds Educate pt. Check pt's chart Scenario #3 Hand hygiene Set up supplies Apply clean gloves Gently peel off Clean wound site Apply new dressing Scenario #4 Notify HCP Inform pt. Initiate cardiac telemetry Give 1L NS Empty foley Scenario #5 Explore why pt. Educate pt. Evaluate pt's understanding Contact social services Involve family

Educational- increased Fall Risk - increased Health Change - increased Pain - increased PsychologicL Needs - increased Neurological - normal

Chronic pain Impaired comfort Deficient knowledge Fear of death Gas exchange, risk for Infection, fisk for

Scenario #1 Full assessment Contact IV team Contact HCP Set up PCA Contact social services Scenario #2 Administer ABX & start morphine Contact hospice/social work Place pt. on continuous pulse ox Reassess effectiveness Document Scenario #3 Reassess VS & elevate HOB Continue to provide Seek clarification Call respiratory therapy Provide emotional support Scenario #4 Full assessment Place pt. on 100% non-rebreather Review PCA pump history DNR armband Discuss with HCP Scenario #5 Contact HCP Contact chaplain Take pt's family Prepare Mrs. Knox's body Notify social services

Educational - increased Fall Risk - increased Health Change - increased Pain - normal Psychological Needs - normal Neurological - normal

Impaired mobility, risk for Deficient knowledge Impaired gas exchange, risk for Peripheral neurovascular dysfunction, risk for Risk for infection Ineffective breathing pattern

Scenario #1 Reposition HOB to semi-fowler's Increase supplemental O2 Orient pt. Initiate IS treatment Retake VS Scenario #2 WBC Magnesium RBC Hemoglobin BUN Scenario #3 Stop infusion Don gloves Inspect site Collect supplies Remove IV & document Scenario #4 Have secretary Review current Discuss the policy Ask Hildegard Document teaching Talk to daughter Scenario #5 Don gloves & assist pt. Assess stool Assist pt. to bed Anticipate need Call the physician Place pt. on enteric

Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Neurological - normal

Acute pain Bleeding Impaired comfort Deficient knowledge Infection, risk for

Scenario #1 Explain to pt. Medicate pt. Initiate IV Put an arm band Ask pt. Scenario #2 Explain to Mrs. Whitmore Inform pt. Explain to pt. Reassure pt. Ask Mrs. Whitmore Scenario #3 Contact charge nurse Contact hospital liaison Inform pt. Inform admitting physician Document Scenario #4 Ask pt. Administer Epoetin Pt. teaching Administer diluted iron Reassess pt. Scenario #5 Remind surgeon & staff Notify HIPAA Notify charge nurse Suggest Introduce hospital liaison

Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - normal Neurological - normal

Acute pain Bleeding, risk for Impaired mobility, risk for Nausea Deficient knowledge

Scenario #1 Wash hands Complete full assessment Medicate Encourage positioning Orient friend Scenario #2 Complete neuro Educate Jody's parents Offer full AM bath Log roll pt. Ensure foley is draining Scenario #3 Inform pt. & family Draw stat D-Dimer Obtain additional support Ask parents Accompany pt. Scenario #4 Start O2 100% Provide SBAR Page surgeon STAT Prepare for heparin Assist RRT Scenario #5 Assist & support Alert ICU Following pt. arrival Provide emotional support Ask charge nurse

Educational - increased Fall Risk - normal Health Change - increased Pain - normal Psychological Needs - normal Neurological - normal

Deficient knowledge

Scenario #1 Offer pt. a urinal Perform post-op Assist pt. Tell pt. Ensure side rails Scenario #2 Assess large dressing site Administer pain meds Assess dressing supply Assess pt's need Document Scenario #3 Restart new IV Administer nausea med Assess for contraindications Weight the pt. Take VS & provide pt. teaching Scenario #4 Complete full assessment Apply clean dressing Encourage pt. Continue to encourage Document & inform Scenario #5 Assess pt's concerns Teach pt. Make referral Consult social services Have pt. verbalize

Educational - increased Fall Risk - normal Health Change - increased Neurological - normal Pain - normal Psychological Needs - normal Sensorium - normal

Enhanced readiness for learning Ineffective health maintenance Imbalanced nutrition Risk for injury

Scenario #1 Ask Mrs. Workman Explain in laymen terms Discuss lifestyle choices Discuss lifestyle changes Document teaching Scenario #2 Asses Mrs. Workman's knowledge Ask Mrs. Workman for 24-hour diet Educate Mrs. Workman Provide Mrs. Workman Ask Mrs. Workman to demonstrate Scenario #3 Assess pt's preferred Ensure the pt. Provide an exercise routine Review with Mrs. Workman Use teach back Scenario #4 Assess pt's blood glucose Provide 20 gram carb Provide another Reassess blood glucose Proved additional teaching Scenario #5 Assess Mrs. Workman's understanding Explain to Mrs. Workman Explore new ways Provide information Document education

Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Neurological - increased

Acute pain Bleeding, risk for Impaired comfort Impaired mobility Deficient knowledge Fall, risk for Infection, risk for

Scenario #1 Complete full assessment Secure help Medicate Contact nursing supervisor Complete bed bath Scenario #2 Reassess VS Report discrepancy Notify HCP Contact IV team Document all findings Scenario #3 Explain to surgeon Check on labs Contact charge nurse Meet with daughter Assess pt. Scenario #4 Provide therapeutic Assess last medication Assist the IV team Explain to daughter Contact social services Scenario #5 Witness daughter Call report 88 y/o female Former nursing home Pt. has a foley Have daughter stay

Educational - increased Fall Risk - increased Health Change - increased Pain - normal Psychological Needs - increased Sensorium - normal

Acute Pain Impaired mobility Impaired skin integrity, risk for Anxiety Deficient knowledge Fall, risk for Decisional comfort Disturbed body

Scenario #1 Check pedal cap refill Educate pt. Evaluate understanding Adjust crutches Assist pt. OOB Scenario #2 Wash & glove VS assessment Administer anit-pyretics Verify call light Document results Scenario #3 Inspect cast site Assess toe movement Notify Dr. Document results Scenario #4 Assess pain Elevate extremity Educate pt. Notify lead nurse/Dr Retrieve cast removal tool Scenario #5 Use therapeutic Notify lead nurse/Dr Consult social services Evaluation pt. Document consults

Educational - increased Fall Risk - increased Health Change - increased Neurological - normal Pain - normal Psychological Needs - normal

Acute pain Bleeding, risk for Impaired comfort Fall risk

Scenario #1 Introduce Take vitals Auscultate lungs Inspect pleurovac Mark drainage level Scenario #2 Assess VS Assess insertion site Check pleurovac Administer pain meds Encourage use of IS Scenario #3 Asses for mediastinal shift Administer 100% O2 Auscultate lungs Assess pleurovac Cal rapid response Scenario #4 Explain to pt. Obtain 16 gauge angiocath Set up sterile Obtain & fill Assist with insertion Scenario #5 Assess VS Auscultate lungs Complete chest x-ray Inspect insertion site Ensure chest tube

Educational - increased Fall Risk - increased Health Change - increased Neurological - increased Pain - increased Psychological Needs - increased

Acute pain Impaired mobility Fall risk Risk for infection

Scenario #1 Assess current pain Obtain VS Complete initial assessment Educate pt. Place personal aspirin Scenario #2 Assess for injury Obtain assistance Take VS Complete skin assessment Notify healthcare provider Scenario #3 Administer medication Address pt's skin tear Obtain bedside Prepare pt. Assign a UAP Scenario #4 Assess leg Treat pt. Educate pt. Contact power of attorney Collect pre-op labs Scenario #5 Assess VS & UO Start secondary IV Have a 2nd licensed nurse Take VS Assess pt. & VS

Educational - increased Fall Risk - increased Health Change - increased Neurological - normal Pain - increased Psychological Needs - normal

Bleeding, risk for Impaired comfort Deficient knowledge ETOH withdrawal, risk for

Scenario #1 Educate pt. Draw labs Initiate large bore IV Advise pt. Initiate I&O Scenario #2 Stop the pt. Explain to the wife Reassess pt. Call GI provider Explain to pt. & wife Scenario #3 Identify the client Check the client Document necessary Check VS Recheck VS q 5 min Scenario #4 Repeat H&H Administer ordered meds Explain to the pt. Verify with blood bank Verify soft, low sodium Scenario #5 Stop the platelets Reassess VS & obtain UA Notify HCP Call charge nurse Initiate incident report

Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Neurological - normal

Acute pain Deficient knowledge Fall, risk for

Scenario #1 Tell the pt. that Perform admission Tell the pt. to Explain to the pt. Ensure the bed Scenario #2 Explain to the pt. Reinforce the risk Administer the medication Assess if the contents Remove the lunch tray Scenario #3 Assess pt's LOC Elevate HOB Reapply NC Remove the dinner tray Reassess pt. q 5 min Scenario #4 Restart IV Give NS liter bolus Recheck Tilts Remind pt. Draw a repeat CBC Scenario #5 Assess pt's pain If gastric reflux If cardiac Assess pt's anxiety Verify if discharge

Educational - increased Fall Risk - normal Health Change - increased Pain - normal Psychological Needs - normal Neurological - normal

Impaired comfort Deficient knowledge Sexuality

Scenario #1 Complete initial Check patency Medicate for pain Explain to pt. Inform pt. Scenario #2 Tell the wife Explain to Mr. Greer Teach the pt. Evaluate pt's understanding Continue to observe Scenario #3 Using therapeutic Contact HCP Provide the pt. Provide a diversional When the HCP Scenario #4 Complete head-to-toe Ensure pt. privacy Complete secondary Reinforce to the pt. Notify HCP Scenario #5 Ask the pt. if it is okay Explain that Docetaxel Explain that Radium-223 Ask the pt. to verbalize Assess pt's understanding

Educational - increased Fall Risk - normal Health Change - increased Pain - normal Psychological Needs - normal Neurological - normal

Bleeding, risk for Impaired comfort, risk for Impaired mobility, risk for Nausea, risk for Deficient knowledge Infection, risk for

Scenario#1 Wash hands Explain to Roger Obtain & verify Initiate IV Orient pt. Scenario #2 Orient Roger Take VS Observe & mark Assess pain Fluid status Scenario #3 Head-to-toe Reinforce dressing Notify surgeon Notify charge nurse Instruct pt. Scenario #4 Take VS Keep Mr. Clinton Reinforce dressing Initiate secondary Witness signing Scenario #5 Initiate head-to-toe Check operative Assess for pain Review new orders Encourage Mr. Clinton

Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Sensorium - normal

Acute pain Bleeding Impaired comfort Deficient knowledge Fall, risk for

Scenario #1 Explain to the pt. Ensure there is a full Start and IV Medicate Advise pt. Scenario #2 Explain to Mr. Burgandy Inform Mr. Burgandy Ask Mr. Burgandy Reassure pt. Reassess pt's physical Scenario #3 Assess pt's ABCs Take initial VS Pale pt. on O2 Start IV Set-up Scenario #4 Explain procedure Place pt. on 100% O2 Ensure there is suction Obtain chest tube tray Reassess pt's VS Scenario #5 Instruct Mr. Burgandy Notify charge nurse Call security Transport Mr. Burgandy Complete incident report

Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Neurological - normal

Acute pain Deficient knowledge Impaired mobility, risk for Nausea

Scenario #1 Orient pt. Educate pt. Administer rectal Assess IV Insert NG Scenario #2 Describe to pt. Explain how surgery Practice using IS Reinforce need Evaluate pt. understanding Scenario #3 Ensure signed surgical Take VS Ask pt. to verify Check IV Disconnect NG tube Scenario #4 Receive handoff Assess/inspect Take VS Elevate HOB Give pt. call light Scenario #5 Assis pt. Ensure side rails Notify charge nurse Notify HCP Complete incidence report

Educational - increased Fall Risk - normal Health Change - increased Pain - increased Psychological Needs - increased Sensorium - normal

Acute pain Nausea Deficient knowledge

Scenario #1 VS & head-to-toe Collect stool Initiate IV Initiate I&O Teach pt. Scenario #2 Place pt. Relocate pt. Contact HCP Proved PRN Continue strict I&O Scenario #3 Notify Infection Control Pt. education Initiate medication Continue medicating Discuss coping Scenario #4 Allow pt. Educate pt. Evaluate pt. understanding Notify HCP Document Scenario #5 Educate pt. of protocols Educate pt. of transmission Evaluate potential barriers Educate pt. of need Evaluate pt. understanding

Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - normal Neurological - normal

Acute pain Bleeding, risk for Impaired comfort Deficient knowledge Infection, risk for

Scenario #1 Wash hands & assess Complete neuro Check the blood Pre-op education Ask surgeon Scenario #2 Complete neuro Educate pt. Evaluate pt's understanding Administer IV ABX Sign additional Scenario #3 Complete neuro Educate pt. & family Inform healthcare provider Contact social services Extensive discharge Scenario #4 Repeat neuro Reemphasize to pt. Approach resident Contact nursing supervisor Document Scenario #5 Take VS Restart pt's IV Obtain surgical Assure pt. Remain with pt.

Educational - Increased Fall Risk - Increased Health Change - Increased Neurological - Increased Pain Level - Increased Psychological Needs - Increased

Defensive coping Ineffective health maintenance Risk for post traumatic stress syndrome Risk for injury at home

Scenario #1 Wash hands Reassure pt. Interviewing pt. Complete physical Notify charge nurse Scenario #2 Use therapeutic Seek clarification Reassure Mr. Jones Administer prescribed Offer UAP Scenario #3 Assess Mr. Jones Assist Mr. Jones Provide personal Remind Mr. Jones Obtain a sitter Scenario #4 Notify HCP Administer nebulizer Reassess respiratory Encourage Mr. Jones Document Scenario #5 Talk with Mr. Jones Call Mr. Jones's children Ask Mr. Jones Discuss options Notify the social worker

Educational - increased Fall Risk - increased Health Change - increased Neurological - normal Pain - increased Psychological Needs - normal

Acute pain Deficient knowledge Impaired mobility, risk for Nausea Bleeding, risk for

Scenario #1 Check for cognition Check pupils Check nose and ears Check cranial nerves Assess extremity Scenario #2 Explain to Mr. Wiggins Inform pt. Ask pt. to remain Put side rails up Notify physician Scenario #3 Contact radiology Inform the pt. of the plan Start a saline lock Inform pt. why you are doing Inform the pt. why he will Notify charge RN Scenario #4 Remain with pt. Call for help Note time when Ensure IV access Reassess VS Scenario #5 Assist anesthesia Administer Valium Initiate a second 18g IV Contact family Continue frequent VS

Educational - increased Fall Risk - normal Health Change - increased Pain - increased Psychological Needs - increased Sensorium - normal

Acute pain Readiness for enhanced immunization status Ineffective coping Rape-trauma syndrome Fear Grieving Infection, risk for Disturbed energy field Anxiety Compromised family coping Social isolation

Scenario #1 Use therapeutic Full assessment Provide emotional Document Scenario #2 Use therapeutic Educate pt. Provide supplies Offer to assist Scenario #3 Use therapeutic Ask open-ended Seek clarification Summarize Scenario #4 Restsate or paraphrase Acknowledge Review plan Notify social services Document Scenario #5 Review labs Educate pt. Provide emotional Discuss support

Educational - increased Fall Risk - increased Health Change - increased Neurological - normal Pain - increased Psychological Needs - normal

Acute pain Altered body image Impaired physical mobility Impaired tissue integrity Risk for imbalanced nutrition Risk for infection Risk for injury related to falls

Scenario #1 Assess current pain Assess documented pain Review medication Prepare and administer Reassess pain Scenario #2 Asses Mr. Wright's willingness Eliminate as many Explain rationales Assess understanding Document Scenario #3 Remove old dressing Assess the injury Assess and document Measure wound size Re-apply new sterile dressing Scenario #4 Don clean gloves Remove clean gloves Clean wound Place sterile moistened Secure dressing Scenario #5 Explain S/Sx Encourage Mr. Wright Assess understanding Alert Mr. Wright's case manager Call Report

Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - normal Sensorium - normal

Deficient fluid volume Electrolyte imbalance, risk for Fatigue Fall, risk for Noncompliance

Scenario #1 Assess I&O Construct dietary consult Acquire daily weight Evaluate outcome Scenario #2 Full assessment Check I&O Teach pt. about safety Document Scenario #3 Wash/glove hands Provide emesis basin VS assessment Administer antiemetic Evaluate medication Scenario #4 VS assessment Assessment of bowel Administer protocol Document results Include pt. condition Scenario #5 Inform & educate spouse Evaluate/modify Assess food Document

Educational - increased Fall Risk - normal Health Change - increased Pain - normal Psychological Needs - normal Sensorium - normal

Impaired coping Risk for impaired comfort Infection risk Risk for injury

Scenario #1 Apply O2 Connect pt. Complete full assessment Obtain IV access Orient pt. & husband Scenario #2 Give IV morphine Reassess VS Notify Cath lab Obtain informed consent Transport pt. Scenario #3 Take VS Post-op assessment Ensure pressure dressing Instruct pt. Assess pain Scenario #4 Explain the necessary Perform hand hygiene Remove infiltrated IV Don new gloves Insert new IV Scenario #5 Asses pt. & family Provide pt. post MI Pt. & family should Schedule cardiac Document

Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - normal Sensorium - normal

Acute pain Impaired mobility, risk for Impaired urinary elimination Fall, risk for

Scenario #1 Wash & glove Vital assessment Administer Reassess pt. Document Scenario #2 Vital assessment Notify Dr. Administer new Reassess pt. Scenario #3 Use therapeutic Obtain urinary Assist pt. Remain w/ pt. Document Scenario #4 Use therapeutic Educate pt. Evaluate understanding Contact dietary Document Scenario #5 D/C instruction Evaluate understanding Escort pt. Document Notify housekeeping

Educational - increased Fall Risk - normal Health Change - increased Neurological - normal Pain - increased Psychological Needs - increased

Acute pain Deficient knowledge Grieving impaired comfort Infection

Scenario #1 Have pt. Wash hands Use therapeutic Guide her back Set her up Scenario #2 InitiateO2 Scenario #3 Contact RT Obtaintelemetry Ask PCT Don PPE Assist RT Scenario #4 Call rapid response Continue to assist Give SBAR Call for crash cart Ensure documentation Scenario #5 Encourage the HCP Offer to contact Contact assisted living Notify HCP Assist w/ intubation

Educational - increased Fall Risk - normal Health Change - increased LOC - normal Pain - increased Safety - increased Psychological Needs - normal Sensorium - normal

Acute pain Knowledge deficit Nutrition Risk for infection Skin integrity at risk Fera/anxiety

Scenario #1 Perform full assessment Provide comfort Check surgical consent Inform his partner Scenario #2 Educate about recovery Discuss his understanding Offer assistance Determine from medical Scenario #3 You discuss this cough Notify Dr. of change Explain to Mr. Dominec Explain that he will Notify charge nurse Scenario #4 Inform pt. about Obtain and provide Encourage Mr. Dominec Document and provide Scenario #5 This information Remind staff Leave the break room Report this activity

Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - normal Sensorium - normal

Bleeding, risk for Deficient fluid volume, risk for Impaired mobility Fall, risk for Infection, risk for

Scenario #1 Wash & glove Full assessment Allow expression Educate pt. Evaluate understanding Scenario #2 Wash & glove Full assessment Check NG tube Administer IV antiemetic Scenario #3 Full assessment Educate pt. Evaluate understanding Notify lead RN Consult wound care Scenario #4 Discuss w/ pt. Notify lead RN Contact social services Update pt. Scenario #5 Follow HIPAA Explain HIPAA Offer resource Contact wound care Document

Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - normal Sensorium - increased

Acute pain Deficient knowledge Fall risk

Scenario #1 Perform hand hygiene Reassess BP & P Evaluate pt's understanding Administer Document Scenario #2 Retake VS Instruct pt. Perform comfort Request CNA Notify the HCP Scenario #3 Pt. Kenny Barrett Pt. was admitted Current VS Request possible change Scenario #4 Take VS not Maintain strice 500 mL NS Hold next dose Contact HCP Scenario #5 Assess stress level Communicate Discuss willingness Educate pt. Contact HCP

Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Sensorium - increased

Bleeding, risk for Imbalanced nutrition Self-care deficit Acute confusion Fall, risk for Failure to thrive

Scenario #1 Perform neuro Reorient pt. Assess for fall Offer nutrition Scenario #2 Explain reason VS assessments Apply restraint Perform circulatory Request sitter Scenario #3 Employ therapeutic Release restraints Reapply restraints Perform circulatory Document Scenario #4 Use therapeutic Attempt to orient Perform circulatory Offer nutrition Document Scenario #5 Check monitor Apply NC O2 VS reassessment Notify lead RN Remain w/ pt.

Educational - increased Fall - increased Health Change - increased Neurological - normal Pain - normal Psychological Needs - normal

- Death anxiety - Impaired gas exchange - Ineffective breathing pattern

Scenario #1 Don appropriate PPE Change to simple Perform focused Notify respiratory therapy Notify family Scenario #2 Reorient pt. Obtain a sitter Restart IV Begin strict Obtain an order Scenario #3 Use therapeutic Position the pt. Create sterile Instruct Lucy Insert foley Scenario #4 Make sure O2 mask Ensure pt. Check the foley Notify RRT Provide initial Scenario #5 Mr. Raymond, COVID-19 Pt. has a HX Intubated by Recommend pt. Accompany pt.

Educational - increased Fall - increased Health Change - increased Pain - increased Psychological Needs - increased Sensorium - normal

- Acute pain - Anxiety - Disturbed personal identity - Impaired physical mobility - Impaired skin integrity - Risk for post trauma syndrome

Scenario #1 Wash hands Assess respiratory Do not disturb Reduce stimuli Document Scenario #2 Wash hands Assess Ms. Horton's Medicate Attempt deescalation Document Scenario #3 Gather supplies Wash hands Explain procedure Provide morphine Perform dressing Scenario #4 Educate Ms. Horton Reinforce past Educate family regarding active Educate family regarding intervention Document Scenario #5 Assess Ms. Horton's Use therapeutic Assist Ms. Horton Escort pt. Provide report

- Educational - increased Fall Risk - increased Health Change - increased Pain - normal Psychological Needs - increased Sensorium - increased

- Electrolyte imbalance - Imbalanced fluid volume, risk for - Ineffective renal perfusion, risk for - Acute confusion - Fall, risk for - Failure to thrive

Scenario #1 Wash and glove Full assessment Monitor and evaluate Educate pt. Document Scenario #2 Wash and glove Full assessment Apply fall risk Document Scenario #3 Offer assistance Remain with pt. Therapeutic communication Notify lead nurse Document Scenario #4 Visual asess Call rapid response Apply oxygen Establish second Remain with pt. Scenario #5 Give verbal Escort pt. Notify family Document

Educational - increased Fall Risk - normal Health Change - increased Neurological - normal Pain - normal Psychological Needs - normal

- Knowledge deficit - Risk for infection

Scenario #1 Establish responsiveness Call for code Check for breathing Begin continuous When help arrives Scenario #2 Assist with airway Assist with applying Establish large IV Provide pt. hx Provide medical hx Scenario #3 Check time Establish when the cardiac Begin list of medications Document rhythm Remind CODE Scenario #4 Ensure cardio pads Charge the monitor Announce to CODE Announce, "CLEAR Ensure no one Scenario #5 Give 1mg atropine Reassess its VS Repeat 1mg atropine Prepare for external Document and accompany

- Educational Needs - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Sensorium - normal

- Acute pain - Electrolyte imbalance, risk for - Impaired comfort - Deficient knowledge - Fall ,risk for - Infection, risk for

Scenario #1 Introduce yourself Full assessment Educate pt. Evaluate understanding Provide comfort Scenario #2 Wash/glove Inspect pain Check proper Verify call light Notify doctor Scenario #3 Educate pt. Evaluate understanding Remove NG Order a new clear Document Scenario #4 Wash/glove Full assessment Encourage Verify call light Document Scenario #5 Use therapeutic Educate pt. Evaluate understanding Verify call light Document

- Educational Needs - increased - Fall Risk - increased - Health Change - increased - Neurological - increased - Pain - normal - Psychological Needs - increased

- Acute pain - Anxiety - Impaired tissue perfusion - Ineffective health maintenance - Powerlessness - Drug therapy

Scenario #1 Assess airway Ensure continuous Administer oxygen Provide morphine Reassess pt's VS Scenario #2 Assess for the abrupt Initiate IV heparin Give ASA Observe for bleeding Monitor aPTT Scenario #3 Provide emotional Assess MR. Martinez's willingness Provide introductory Report Mr. Martinez's Document Scenario #4 Troponin CPK CK-MB Serum Potassium Serum Sodium Scenario #5 Clarify Promote open Explain to Mr. and Mrs. Discuss physical Provide information

Educational Needs - increased Health Change - increased - LOC - normal - Pain - increased - Psychological Needs - normal - Safety - increased

- Pain, acute - Physical mobility, impaired - Skin integrity, impaired - Knowledge deficit - Disturbed body image

Scenario #1 Ask pt. to explain If pt. statement Stay with pt. Contact head RN Procedure is scheduled Scenario #2 Therapeutic communication Validate NPO Encourage to ambulate Connect telemetry Provide a few chairs Scenario #3 Vital signs taken Complete assessment Talk with her Allow husband Document Scenario #4 Provide operative summary Present health assessment Report current Request time Explain to her family Scenario #5 Full assessment of pt Provide for physical Therapeutic communication Begin post-op Notify family

- Educational Needs - increased - Fall Risk - increased - Health Change - increased - Pain - normal - Psychological Needs - increased - Sensorium - normal

- Fatigue - Impaired gas exchange - Ineffective airway clearance - Noncompliance - Anxiety - Deficient knowledge - Fear - Readiness for self-care enhancement - Social isolation, risk for

Scenario #1 Don PPE Allow for non-compliance Do not probe Verify call light Document Scenario #2 Obtain translator Offer masks Educate pt Evaluate understanding Obtain Spanish Scenario #3 Obtain translator Wash hands Put on gown Don gloves Administer Scenario #4 Educate caller Evaluate caller Refer caller Notify doctor Document Scenario #5 Obtain translator Use therapeutic Educate pt. Evaluate learning Document

- Education Needs - increased - Fall Risk - increased - Health Change - increased - Neurological - normal - Pain - increased - Psychological - normal

- Acute pain - Impaired comfort - Impaired mobility - Fall, risk for

Scenario #1 Perform initial Ask the pt. if she Ask the pt about Ask if the pt. understands Ensure informed consent Scenario #2 Comfort the pt Provide education Explain the TX Evaluate pt. Document Scenario #3 Assist the pt. Perform Draw digoxin Request order Place call light Scenario #4 Assess the pt. Establish an IV Administer digoxin Monitor for adverse Request repeat Scenario #5 Check leads Perform Start O2 Call RRT Educate pt

- Educational Needs - increased - Fall Risk - increased - Health Change - increased - Neurological - increased - Pain - normal - Psychological Needs - normal

- Disturbed body image - Ineffective health maintenance - Risk for malnutrition - Impaired tissue integrity - Risk for physical injury - Self-care deficit

Scenario #1 Wash handa Obtain blood (culture #1) Obtain blood (culture #2) Initiate IV Administer levofloxacin Scenario #2 Ask the pt. Assess VS Place the syringe Notify the charge Call HCP Scenario #3 Assess VS Therapeutic communication Call HCP Prescribed medication Assess for therapeutic Scenario #4 Ask Mrs. Pittman Perform pre-op Ensure signed consent Ensure type and cross Have IV ABX Scenario #5 Pre-medicate Don clean gloves Monitor neurovascular Don 2nd set Elevate stump

- Educational - increased - Fall Risk - increased - Health Change - increased - Pain - increased - Psychological Needs - increased - Sensorium - normal

- Chronic pain - Constipation, risk for - Imbalanced nutrition - Anxiety - Fear - Grieving - Hopelessness - Powerlessness

Scenario #1 Wash and glove Full assessment Seek clarification Check PRN Verify call light Scenario #2 Full assessment Educate pt. Place pt. Observe closely Perform pain Scenario #3 Use therapeutic Educate pt. Notify doctor Contact social services Report Scenario #4 Use therapeutic Notify MD Education Insert Document Scenario #5 Allow family Full assessment Provide comfort Pain reassessment Document

- Educational Needs - increased - Fall Risk - increased - Health Change - increased - Pain - increased - Psychological Needs - normal - Sensorium - normal

- Acute pain - Bleeding, risk for - Impaired mobility - Fall, risk for - Ineffective health maintenance - Infection, risk for

Scenario #1 Assess for bowel Administer PRN Encourage fluids Evaluate understanding Review pain Scenario #2 Check physician Educate pt. Offer bedpan Record I/O Verify call light Scenario #3 Obtain VS Wash and glove ID pt. Assess vital Document Scenario #4 Wash and glove Administer antipyretic Encourage fluids Notify doctor Document Scenario #5 Notify PT PT to educate Read PT Reassess pt. Evaluate/modify