Vital signs and pain
Your client's BP is 90/54. What would a nurse do?
Check Vital Sign trends and if this is lower and symptomatic:
Place patient in bed, head of down
Retake BP and check rest of vital signs
Check I/O
Start an IV
Text provider if symptoms continue
Anything else?
Chart
Your patient's NGT output contents have doubled over the last hour.
What would a nurse do?
Verify patient's LOC and Vital signs
Verify patient's oral intake
Measure output
Test for occult blood if allowed by institution
Save output for testing
Assess for nausea
Contact provider with amount, time it has doubled and appearance of output
Chart
Your client's wound has purulent drainage.
What would a nurse do?
Review chart to see if this is a new finding
Remove dressing and assess site for bleeding and amount of drainage
If new and there has been significant changes to the wound contact provider or wound care
Follow instructions to cover wound until they arrive
Chart your findings and actions
What are 5 steps of the nursing process
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
Your patient is admitted with shortness of breath.
What are three priority assessments for this patient.
What would a nurse assess?
1. Vital signs including SPO2
2. Breath sounds
3. Ability for patient to speak in full sentences
4. Sputum production
Your client's oral temperature is 102.3F or 39C
What would a nurse do?
Assess the rest of the vital signs, including O2 sat
Contact provider
Insure patency of the IV site
Monitor status
Be prepared to collect cultures...blood, urine, sputum
Chart everything
Your client's closed suction bulb drain (Jackson Pratt) has 350 ml of bloody drainage over the last 4 hours.
What would a nurse do?
Check I/O from prior shifts
Check vitals signs
Observe insertion site for swelling or leaking
Ask patient about pain or other symptoms.
Empty bulb syringe and reserve drainage
Observe for further drainage.
Contact provider if it fill quickly
Chart
Your client has a large knot of hair on the back of their head. The patient is bedridden and is frequently lying on the back, on this knot of hair.
What would a nurse do?
Bring this to the attention of the provider
Assess the skin under the knot of hair for breakdown
If you have permission to wash hair (ICU):
Shampoo hair and heavily condition
Leave conditioner in at 30-45 minutes until tangle
loosens and starts to come apart
If that fails, vegetable oil or olive oil
Small amount of rubbing alcohol into the knot will breakdown product and protein in hair
Never cut hair without an order and permission from patient or representative
Never throw cut hair away, always offer it bagged to the family
Restyle ( with family if available) hair pulled to the side as not to create a bump or pony tail that will cause skin damage to the back of the head
How does a nurse establish a database for the patient?
Obtain a health history
Review client records
Consult support personnel
Organize the data
Validate the data
Communicate the findings
You are admitting a patient with abdominal pain.
What name three priority assessments for this patient
1. Assess vital signs
2. Describe pain, location, consistency and anything that makes it better or worse
3. Any nausea or vomiting
4 Blood in stool
5. Blood in urine, any pain while voiding
6. Last menstrual period, ? pregnancy
7. Last meal
8. Bowl sounds
8. Ever had this pain before
Your client's heart rate has doubled.
What would a nurse do?
Assess other vital signs.
Inquire about pain
12 lead EKG
Contact provider for further orders
Chart
You've inserted an intermittent catheter (straight cath) a patient and drained 900 ml of clear urine as the bladder continues to drain.
What would a nurse do?
Clamp catheter at 1000 ml
Evaluate patient tolerance
Continue to drain if well tolerated
Consider a PVR scan when urine has stopped flowing to evaluate bladder.
Chart
Your client's surgical wound has dehisced.
What would a nurse do?
Stop bleeding
Cover with NS soaked gauze
Contact surgeon
Monitor vital sign
Prepare to go to the OR
Contact family
CHART
How does a nurse determine a nursing diagnosis?
Compare data against the standard
Identify gaps
Determine client's strengths, weaknesses and problems
You are assessing a patient with headache.
What will the nurse assess?
1.Onset of symptoms
2. Vital signs
3. Assess scalp, head and neck for signs of swelling and injury
4. photophobia
5. similar headaches in the past
You witness a family member pushing your client's PCA button as he sleeps.
What would a nurse do?
Immediately assess the clients vital signs and mental status
Ensure ETCO2 is in place and monitor alarms are on
Educate family members on the dangers of pushing PCA button while patient is asleep
Leave patient door open for observation
Make frequent trips to the room
Notify supervisor
If behavior persists, notify security
Chart all actions and conversations
Your male client's indwelling catheter has been accidently pulled out with the balloon intact. He is bleeding from the urethra.
What would a nurse do?
Contact the provider.
Prepare for urology consult
Consider a PVR bladder scan before you call the provider
Provide the client with a urinal
Monitor I/O
Prepare to replace catheter and set up bladder irrigation
Chart
Your client has a new large skin tear on the right forearm that is bleeding
What would a nurse do
Control the bleeding
Gently clean the wound with warm water
Gently pat it dry
If the flap is attached, try to replace it by gently rolling it over the wound.
Cover the wound with clean, non stick pad
Do not cut flap off
Cover with clean no stick pad
Secure with stockinette
Measure and record wound
Inquire about how it happened
If in a facility, an incident report must be made per facility policy
Is there a limit on the number of nursing diagnosis that a patient can have?
Only limited by what can be reasonably addressed during hospital stay
You have a patient with a new onset of slurred speech
What would a nurse do?
Immediately call a stroke alert
Monitor vital signs and LOC until team arrives
Your client has developed a right sided facial droop.
What would a nurse do?
Immediately call a stroke alert and prepare patient for testing.
Assess patient VS and Blood glucose
Assess LOC
Have someone contact family
Have Code cart outside the room
Maintain patient safety
Chart
The health provider contacts you and states they will be up in 15 minutes to do a thoracentesis.
What should a nurse do?
Inform the patient and provide patient education
Instruct patient how to lean over bedside table
Contact portable ultrasound to identify fluid to be removed
Gather supplies. Thoracentesis kit and 2 vacuum bottles. Local anesthesia at bedside
Clear time to assist
Have oxygen ready
Chart all actions and patient repsonse
You discover a new stage 2 injury on your patient's coccyx
What would a nurse do?
Measure and describe in charting
Reposition patient on their side and keep them off their coccyx
Contact provider for wound care referral
Document all actions and phone calls
Incident report per hospital policy
What is the purpose of nursing process?
To use a scientific method to critically determine the needs of a patient and develop actions to address/resolve those needs
You are called to Code Blue/Medical emergency in the cafeteria.
What are three assessment a nurse would make upon arrival/
Check for pulse and respirations
Check for obvious physical injuries from the fall
Check for choking
Check blood glucose, treat hypoglycemia