1. Case Study #1

2. Her orders include the following:
Mrs. Jackson is a 72 year-old female that had bowel resection surgery this morning for colon cancer.
Her orders include the following:
Diet: NPO
Oxygen prn
Incentive Spirometer Q1 hour while awake
JP (bulb) Drain
Foley catheter to gravity
D5½ 125mL/hr
Potassium 500mg po BID
Synthroid 125mcg po daily
Vancomycin 1gm IVPB Q8hrs
Percocet 2 po q4hrs prn

3. Mrs. Jackson was admitted to the surgical unit
Mrs. Jackson was admitted to the surgical unit. Her daughter is at her bedside. About an hour after Mrs. Jackson was admitted to the unit, you are assigned as the nursing student to care for her. You and your instructor are entering the room to administer her IV antibiotic, Vancomycin. As you enter the room Mrs. Jackson is vomiting in an emesis basin.

4. What would you do?
After cleaning up the patient, what assessments would you make?
What made this patient at risk for vomiting?

5. Mrs. Jackson says she is in a lot of pain.
What would you do?

6. Mrs. J says that her pain sharp/stabbing in her abdomen and rates her pain at an 8 on a 0-10 scale.
What is the location of her pain?
What is the intensity of her pain?
What is the quality of her pain?

7. After looking at the MAR, you see she is ordered Percocet 2 tabs every 4 hours PRN.
What would you check before giving this med?
What are your concerns for this order?
What would you do?

8. The physician writes an order for a PCA of Hydromorphone
The physician writes an order for a PCA of Hydromorphone. While waiting on the pharmacist to verify and load your medication into the Pixis, you notice an incentive spirometer at her bedside.
Is this a good time to have her use her incentive spirometer?
Why or why not?

9. The nurse for Mrs. Jackson returns to the room with the medication for the PCA pump. The nurse and your instructor perform a 2-nurse verification and set up the PCA pump.
Up to this point, what needs to be documented?
When do you document the new PCA pain medicine?

10. Two hours after Mrs. J has been on the PCA pump, she rates her pain 3/10. You decide this would be a good time to encourage her incentives spirometer.
Explain the steps to educate Mrs. J on the use of her incentives spirometer.

11. Mrs. J continues to have many episodes of vomiting large amounts of emesis. The doctor writes in order for a NG tube to be placed and connected to suction.
What position and technique would you use for the insertion of this NG tube?
What is the best way to check placement of this NG tube?
Would you put the suction on intermittent or continuous suction?

12. What position would you place of Mrs. J at this time?
The RN asks you to administer the patient’s PO Synthroid.
Explain how you would administer this med.

13. Four hours later you assess the patient’s I & O and noticed that there is 60 mL of urine in her Foley bag.
Your nursing instructor asks you if you are concerned about this assessment. Explain your thoughts.
What would you do first after this assessment?
What would you do next?
What would you anticipate the physician ordering?

14. Write a nursing diagnosis for a patient with the Foley.
Write a goal for a patient with the Foley.
List five nursing interventions for a patient what the Foley.

15. While you’re in Mrs. J’s room, you assess her wound
While you’re in Mrs. J’s room, you assess her wound. You find her incisional area is minimally pink, well approximated, slightly warm to touch. The Jackson Pratt drain is round and is full of fluid.
What are your next steps?

16. It is now the end of your shift and the patient is settling in with her pain now under control, her NG is in place and working, and the Foley catheter is draining. You have instructed the patient not to get up out of bed, but you are a little worried she might forget to call for help in the middle of the night since she is in a strange place and on pain medication.
What is the number one thing you can ensure the patient understands about safety prior to leaving the room?

17. The next week you return and once again are assigned to Mrs. Jackson
The next week you return and once again are assigned to Mrs. Jackson. Her NG tube, Foley and PCA pump have been removed. Over the past week Mrs. Jackson has gotten weaker, begun having diarrhea, and even fallen out of bed. She has diminished breath sounds bilaterally. She continues to have an IV of D NS running at 100 ml/hr.
Write 4 nursing diagnosis for Mrs. J.

18. You go in to see Mrs. Jackson and complete her vital signs and assessment. While doing the assessment of her skin, you notice that she has 3 red, round oval blisters that are fluid filled on her abdomen close to her incision. When asked what caused these blisters, Mrs. J said she had a reaction to the tape. You also note that she has a reddened, nonblanchable area on her coccyx.

19. Write a nursing diagnosis, a goal statement and 3 nursing interventions based on these findings.
Write a narrative documentation about these findings.
What additional interventions would you add because of Mrs. J having diarrhea?

20. During your assessment, you assess Mrs. Jackson’s bladder
During your assessment, you assess Mrs. Jackson’s bladder. She winces when you palpate.
What would you ask Mrs. Jackson?

21. She states that she cannot remember, but that she can try to get up to void now. You proceed to help Mrs. Jackson up to the bedside commode. This is the first time she has been up this morning and she is week.
What device would you use to assist her to the commode?

22. When you first stand Mrs. Jackson up, she states that she feels dizzy.
What would you do?

23. Once Mrs. Jackson states that the dizziness has passed, you proceed with helping her to the commode. She is able to void and you assist her with wiping/cleaning herself. While assisting her you notice that her pulse ox drops from 98% to 84%.
What would you do?

24. Knowing that Mrs. Jackson is having frequent diarrhea and witnessing her experience with your assistance in getting up to the commode,
What is Mrs. Jackson at risk for that could cause severe injury?

25. In continuing your assessment of Mrs
In continuing your assessment of Mrs. Jackson you know that you still need to assess her incision and her pain level. Her incision is partially open this week and they are performing wet-to-dry dressings q shift.
You know as a nursing student that the reason for this type of dressing is that?

26. Currently Mrs. Jackson’s pain level is at 6
Currently Mrs. Jackson’s pain level is at 6. You know the dressing change can be painful. It is not time for another dose of pain medication, but the nurse has instructed you that the dressing needs to be changed now because Mrs. Jackson will be leaving the unit soon for PT.
What can you do for Mrs. Jackson’s pain?

27. You receive an order for additional pain medication and administer the medication with your instructor. You then proceed with the wet-to-dry dressing change. You note that the drainage is minimal, but that the wound appears to be black along one side. You notify the physician and he states that he will be down this afternoon to see the patient. Physical Therapy arrives and your nursing instructor tells you to go with the patient to therapy. About 10 minutes into the session, while ambulating, the patient states that she doesn’t feel well and begins to pass out.
What do you and the physical therapist do for the patient?

28. The physician later arrives to assess the patient and determines that the patient needs to return to the operating room and have a surgical debridement of the wound. Upon further examination of the patient’s labs, he notes that the patient’s Hgb is 7.4. He orders two units of Packed Red Blood Cells to be given STAT. He then squeezes the patient in at the end of the day on the surgical schedule for the debridement.
What is your priority when administering blood?

29. What is the procedure for assessment with administering blood?

30. While the blood is running and prior to the patient going to surgery, you have a little bit of time to clean up the patient.
What is the purpose of bathing a patient especially before surgery?

31. After the blood is administered and the patient is clean and ready to go. The nurse goes in to get the patient’s signature on the surgical consent. The patient and her family appear confused and not able to articulate why she is going back to surgery.
What should the nurse do?

32. A week later you return and are assigned to Mrs. Jackson once again
A week later you return and are assigned to Mrs. Jackson once again. She is feeling much better this week. She is almost ready to go home, but is still having some diarrhea.
Write a goal for Mrs. J.

33. Case Study # 2
Mr. Sanchez was admitted from the emergency department to the unit you are assigned to for your clinical rotation. He is an 88 year old with a history of CHF, respiratory failure, renal disease, throat cancer, and diabetes type II. He was in a car accident and is being admitted for respiratory distress. He has a tracheostomy that has been in place for many years, a chest tube due to a pneumothorax caused in the accident, an IV, and Foley catheter. The patient is Spanish speaking and his family is on their way to the hospital.
Upon arrival to your unit the nurse reviews his orders from the ED physician and notices that they are handwritten instead of being entered in to the computer as per protocol.
What should the nurse do?

34. When going into assess the patient, the nurse realizes that she is unable to communicate with the patient.
What should she do?

35. When the patient’s family arrives, they too speak very little English
When the patient’s family arrives, they too speak very little English. The interpreter stays to assist with communication between the patient, family, and caregivers.
While completing the patient’s history, the patient’s family states that the patient has a living will and requests that no life sustaining measure be taken. The patient is moderately confused from what the nurse can gather and the family has appropriate paperwork giving the daughter power of attorney. When presented to the physician caring for the patient on the unit, he writes a DNR order for the patient.
What does this mean?

36. In his confused state, Mr. Sanchez is pulling at the chest tube and IV
In his confused state, Mr. Sanchez is pulling at the chest tube and IV. He is unable to understand that he is not supposed to pull at them.
What can the nurse do to stop Mr. Sanchez from pulling at these items?

37. During further assessment of Mr
During further assessment of Mr. Sanchez, the nurse notes that his bowel sounds are hypoactive.
What should the nurse ask his family?

38. While assessing his vital signs, the nurse notes that his respiratory rate is in the 30s, his heart is 142, and his B/P is 88/67. His oxygen saturation is 88%. They did not have oxygen on him when they brought him up from the ED despite his diagnosis of respiratory distress and this is the first time the nurse has had time to check his vitals. She also notes that he has “gurgling” coming from his trach.
What should the nurse do first?

39. What is another thing the nurse can do to facilitate exchange of oxygen?
What is a nursing diagnosis for this patient?
What else does the patient have that the nurse should check?
 What does the nurse need to check on the chest tube?
What does the nurse access on the IV?
What does the nurse access with the Foley?

40. The next week the patient is doing better
The next week the patient is doing better. The IV and Chest tube have been removed, but the prognosis for a full recovery is not good. The physician speaks to the family about the patient’s prognosis. Together they decide to set the patient up with hospice since the life expectancy is only about 6-12 months.
What is an important factor to understand when dealing with a family regarding the impending death of a loved one?

41. Finally, what are three things to consider for nursing care when dealing with a terminally ill patient?