Depression/Overdose with Psychosis
Student Simulation Preparation: GI/ Sepsis
|
Student Learning Objectives: 1. Focused post-op assessment 2. Assess and care for colostomy 3. Assess for signs and symptoms of sepsis 4. Educate patient on colostomy care. |
|
Preparation for scenario: Read Pearson Module 10.C – Inflammation Nursing Skills: 4, 4.18 and 4.19 |
GI/ Sepsis Student Worksheet
I. Data Collection
History of Present Problem:
Justine Walsh, is a 45 year old female diagnosed with Crohn’s Disease. Patient admitted through the Emergency Department with abdominal pain and hematochezia for 2 weeks. S/p hemicolectomy with a colostomy. Transferred to the medical/surgical unit for continued care and education. PMH of Crohn’s Disease and anxiety.
Personal/Social History:
Married with two young children. No history of smoking, alcohol or drug use.
| RELEVANT Data from Present Problem: | Clinical Significance: |
| RELEVANT Data from Social History: | Clinical Significance: |
| PMH: | Home Meds: | Pharm. Classification: | Expected Outcome: |
|
Pantoprazole (Protonix) Lorazepam (Ativan) |
1. 2. |
1. 2. |
| Current VS: | WILDA Pain Assessment (5th VS): | |
| T: (oral) 99oF | Words: | sore |
| P: (regular) 88 | Intensity: | 4/10 |
| R: (regular) 20 | Location: | At incision site |
| BP:142/88 | Duration: | surgery |
| O2 sat: 99% on RA |
Aggravate: Alleviate: |
Nothing medication |
What VS data is RELEVANT that must be recognized as clinically significant to the nurse?
| RELEVANT VS Data: | Clinical Significance: |
| Current Assessment: | |
| GENERAL APPEARANCE: | Resting in bed, appears in no acute distress |
| RESP: | Nonlabored respiratory effort. Diminished breathe sounds bilateral LL. |
| CARDIAC: | Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks |
| NEURO: | Alert & oriented to person, place, time, and situation (x4) |
| GI: | Abdomen soft, no bowel sounds audible per auscultation in all four quadrants. Abdomen tender to touch. Colostomy stoma beefy red.. Abdominal incision DSD intact, no drainage noted. |
| GU: | Foley Catheter draining urine clear/yellow |
| SKIN: | Abdominal incision, 14 staples, DSD C/D/I. Colostomy stoma protruding and beefy red. |
What assessment data is RELEVANT that must be recognized as clinically significant to the nurse?
| RELEVANT Assessment Data: | Clinical Significance: |
| Nursing Interventions: | Rationale: | Expected Outcome: |
Medical Management: Rationale for Treatment & Expected Outcomes
| Care Provider Orders: | Rationale: | Expected Outcome: |
|
1. OOB to chair x30 min. BID 2. NPO 3. NGT to low continuous suction 4. Accu check q6hr 5. Foley catheter 6. Strict I&O 7. DSD dressing change daily and prn to keep dry 8. Assess stoma qshift 9. PICC line care |
PRIORITY Setting: Which Orders Do You Implement First and Why?
| Order of Priority: | Rationale: |
Medication Dosage Calculation:
| Medication/Dose: | Mechanism of Action: | Volume/time frame to Safely Administer: | Nursing Assessment/Considerations: |
|
PPN standard at 125ml/hr Morphine 2mg IVP prn q4 hours for moderate pain Cefazolin (Ancef) 2gm IVPB q12hours |
Lab Results:
What lab results are RELEVANT that must be recognized as clinically significant to the nurse?
| Complete Blood Count (CBC:) | Current: | High/Low/WNL? |
| WBC (4.5–11.0 mm 3) | 11.8 | |
| Hgb (12–16 g/dL) | 12 | |
| Platelets (150-450 x103/µl) | 245 | |
| Neutrophil % (42–72) | 43 | |
| Band forms (3–5%) | 4 |
What lab results are RELEVANT that must be recognized as clinically significant to the nurse?
| RELEVANT Lab(s): | Clinical Significance: |
| Basic Metabolic Panel (BMP:) | Current: | High/Low/WNL? |
| Sodium (135–145 mEq/L) | 136 | |
| Potassium (3.5–5.0 mEq/L) | 3.6 | |
| Chloride (95–105 mEq/L) | 96 | |
| Glucose (70–110 mg/dL) | 106 | |
| Calcium (8.4–10.2 mg/dL) | 8.5 | |
| BUN (7–25 mg/dl) | 9 | |
| Creatinine (0.6–1.2 mg/dL) | 0.8 |
| RELEVANT Lab(s): | Clinical Significance: |
| Situation: |
| Background: |
| Assessment: |
| Recommendation: |
ORDER an A++ paper from our MASTERS and DOCTORATE WRITERS
Who We Are
We are a professional custom writing website. If you have searched for a question and bumped into our website just know you are in the right place to get help in your coursework.
Do you handle any type of coursework?
Yes. We have posted over our previous orders to display our experience. Since we have done this question before, we can also do it for you. To make sure we do it perfectly, please fill our Order Form. Filling the order form correctly will assist our team in referencing, specifications and future communication.
Is it hard to Place an Order?
ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT
1. Click on the “Order Now” on the main Menu and a new page will appear with an order form to be filled.
2. Fill in your paper’s requirements in the “PAPER INFORMATION” section and the system will calculate your order price/cost.
3. Fill in your paper’s academic level, deadline and the required number of pages from the drop-down menus.
4. Click “FINAL STEP” to enter your registration details and get an account with us for record-keeping and then, click on “PROCEED TO CHECKOUT” at the bottom of the page.
100% Reliable Site. Make this your Home of Academic Papers.
SCORE A+ WITH HELP FROM OUR PROFESSIONAL WRITERS: ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT
Always Order High-Quality Academic Papers from HERE
5. From there, the payment sections will show, follow the guided payment process and your order will be available for our writing team to work on it.
We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so that it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.
Looking for a Similar Assignment? Order a custom-written, plagiarism-free paper