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Matilda Jackson Date: Day Shift Location: Nanji Foundation Seneca…
Matilda Jackson
Date: Day Shift
Location: Nanji Foundation Seneca General Hospital
Scenario Starts: You come onto your regular medical-surgical floor 10 minutes prior to the start of your shift. The nurse that you will be getting report from is still finishing up their documentation. Based on your assignment, you log into your computer and start to look at one of the patient’s charts. Open Matilda Jackson’s computer charting system and answer the first four questions.
Scenario Continues: The night nurse gives you morning report, based on the IPASS communication system for Feb 1, 2023
I “Watch her!”
P Matilda Jackson, Room 42-2, No known allergies, Isolation: Droplet; Age: 78
Admitting Dx – Fall, weakness, r/o pneumonia, PMHx- diabetes, hypertension
Code – Full.
Arrived from the ED 2 hours ago. Patient takes care of her granddaughters after school until their parents get home. One of the girls was sick over the winter holidays. The patient developed a cough that just made her “catch her breath”. She got winded easily, which made her rest more. She came to the ER because she has just gotten progressively weaker, has no energy. Initially she was just staying closer to home, moving about with her walker. Then she would sit more, then she stayed in bed only getting up for food. She hasn’t really been out of bed for the last week. Because she is not moving, she is not hungry. So, her intake (both food and water) has decreased. She fell trying to get out of bed to the washroom – this is not the first time that she’s fallen. She is doing minimal activity and is not getting better.
Physical Assessment: Neuro – alert, weak grip strength, moderate arm strength, unable to lift leg off bed, fatigues easily, decreased sensation to feet. Respiratory – congested, with a weak cough. O2 Sat 95%, weak cough, RR 20, shallow with increased work to breathe. CV – Pulse 88, 1+ weak/thready pulse, dry skin, dry oral mucus. IV -Right Cephalic vein. Integument – dry skin, redness noted to coccyx area, temp 37.3 C. MSK – Gait impaired, very unsteady, two person pivot assist to wheelchair/commode/chair. GI – diabetic diet, soften diet, eating about ¼ to 1/3 dinner meal. Last bowel movement 2 days ago, small and hard stool. GU – decreased urinary output, wears urinary liner. DROPLET PRECAUTIONS
A VS q4h. Reposition q2h – is a 2-person assist. IV antibiotics q 12h. Check her blood sugar q AC & hs. Blood cultures, CBC and electrolytes already done – awaiting results, needs a Braden Scale assessment.
S Concerned about falls and needs to implementing energy conservation strategies.
S Night Nurse provides opportunity for you to ask questions and ensure that you understand the information given. (You will write this down in Question 5)
Question 1: As his nurse, you are well aware of the negative effects that immobility cause to patient outcomes. Select 3 complications from the list below. For each selected complication, identify 2 relevant, priority interventions along with the rationale for each intervention.
Complications List: A. pressure injuries, B. muscle atrophy, C. blood clots, D. joint stiffness, E. constipation.
[Grand Total of 12 marks]
Complications
Nursing interventions – be specific
(1 mark each)
**CANNOT USE reposition q2h Rationales (Reason why this helps the patient?)
(1 mark each)
1 1
2
2 1
2
3 1
2
Scenario Continues: Mrs. Jackson has been in the supine position for the last two hours. She is having difficulties moving around in bed. Two nurses prepare to reposition Mrs. Jackson into a left lateral.
Question 2: In your own words, briefly write down the steps for this repositioning [Total of 4 marks]
Question 3: Identify exactly what you would say to the patient before, during and after this repositioning. You must communicate to the patient and to the other nurse in the process of repositioning the patient. How do you know that your patient is ready for the transfer? [Total of 3 marks]
Question 4: Identify exactly what you would say to the other nurse in the process of repositioning the patient. How do you know that your patient is ready for the transfer? [Total of 3 marks]
Question 5: You are going to reposition Mrs. Jackson every 2 hours during your shift – indicate what position you will move her into. [Total of 3 marks]
Time Position
0700 Repositioned into Left Lateral (was in supine from night nurse/previous shift)
0900
1100
1300
1500
1700
1900
Scenario Continues: It is 0730 and breakfast trays have arrived on the unit. Review the care order around blood sugars from the chart. The bedside blood glucometer reading is 8.4 mm/L.
**ensure that you open it to see the order details
Question 6: Identify the steps that you would take to obtain the blood sugar. [Total of 2 marks]
Question 7: With the result of 14.3 mmol/L, how much insulin should Mrs. Jackson be given right now? [Total of 1 mark]
Question 8: What does it mean to be ordered a diabetic diet? What should be included and what should not be included? [Total of 2 marks]
Question 9: Mrs. Jackson says, “My neighbour has a tube in her belly that she gets food right into her belly – could I get that?”
a) Tell her 2 advantages and 2 disadvantages of G-tube nutrition [1 mark each]
b) Do you think this is an appropriate intervention for Mrs. Jackson? Provide rationale? [2 marks]
c) c) What exactly would you say to her? [2 marks for therapeutic communication strategies] [Grand Total of 8 marks]
Question 10: Looking back at the repositioning exercise (Question 5), please break down the positions that you would assist Mrs. Jackson for the blood sugar check and for her to eat her breakfast? [1 mark for position – 1 mark for rationale = Grand Total of 4 marks]
Time Position Rationale (Reason why this position will help the patient?)
0700 Write down exactly where they were from question 5 @0700
0730 – Blood sugar check
0800 – Eating breakfast
Question 11: Before leaving Mrs. Jackson to eat her breakfast, what are three things would you want to assess/ do / check before leaving the room? [Total of 3 marks]
Mrs. Jackson in bed before breakfast
Mrs. Jackson’s meal tray
Question 12: You return after breakfast and you complete denture care – identify the steps to remove clean and reinsert the dentures [Total of 2 marks]
Question 13: Update the Oral Health Care Plan in the electronic health record [1 mark]
Main Menu on Left Side – select “Notes.”
1. Bottom Right corner – select “New”
2. Complete a new alert with the following information:
Date Feb 1,
Location: General Hospital
Dentures – full
Morning care – complete
Inserted/Removed by – nurse
Cleaned by: nurse
3. Press Save.
4. Double Check: Reviewing the Electronic Record – Confirm that this was added in the patient header.
5. ***NOTE ***Add Screen shot to your submission or download your session to pdf after completion
Question 14: Complete and document the Braden Scale – base your answers on the details from the IPASS documentation. [1 mark for entering – 0.5 marks for each correct answer (3 marks) – Grand Total 4 marks]
Main Menu on Left Side – select “Notes.”
1. Bottom Right corner – select “New”
2. Complete a new Note with the following information:
Type: Braden Scale for Predicting Pressure Injury Risk
Date – Feb First
**Review the case student for the assessment details for Mrs. Jackson.
Press Save.
3. ***NOTE ***Add Screen shot to your submission or download your session to pdf after completion
Question 15: Mrs. Jackson’s daughter walks in when you are doing active ROM activities. She asks what you are doing, how it is done and why it is helpful to her mother. How would you respond to the daughter? [Total of 2 marks]
Question 16: Based on all of your day’s assessment, what PRIORITY health teaching would be recommended for Mrs. Jackson? [Total of 1 mark]
Scenario Continues: End of Day 1 – you give your IPASS report to the night nurse. Go home for some sleep, as you are back tomorrow morning.
