Student simulation preparation ischemic & hemorrhagic stroke
1. Student Simulation Preparation:
Ischemic & Hemorrhagic Stroke
Student Learning Objectives:
SLO 1-8
9. Perform appropriate neurological assessment.
10. Implement seizure precautions.
11. Prioritize care for increased intracranial pressure.
12. Utilize a communication board.
Patient information: Julie Wilson, a 48-year-old female, brought
into ER by husband after she collapsed at home. Patient
presented confused, complaining of a severe headache and
blurred vision. Diagnosed with ischemic stroke and treated with
rTPA in the ICU. Is currently being treated on the med/surg
floor status post CVA.
Preparation for scenario:
Completion of Student Worksheet (bring with you to sim lab)
Pearson: Perfusion:
Read Pearson Module 16.J & 16. M – (PVD & Stroke)
Nursing Skills:
· Care of a patient with Hemianopsia: Food Tray
· Complete Neuro Check
Skills Set Up:
· Hemianopsia glasses, thickener, Food tray with food
2. I. Data Collection
History of Present Problem:
Julie Wilson, a 48-year-old female, brought into ER by
husband after she collapsed at home this am. Initially was
slightly confused. Complaining of severe right temporal lobe
headache and blurred vision. Husband reports that she was
complaining of headaches and blurred vision that “came & w ent
quickly” over the past 3-4 weeks. CT w/o contrast of right
temporal lobe positive for ischemia. Treated in ICU with rTPA.
Residual left sided weakness noted. Patient transferred to
med/surg floor to begin rehabilitation and for blood pressure
stabilization. Patient noted with edema of bilateral lower
extremity upon assessment by the med-surg nurse.
PMH: HTN, Diabetes – type II, hypercholesterolemia, ½ ppd
smoker and peripheral vascular disease (PVD).
Personal/Social History:
Married for 20 years. Has 3 children who are grown and on their
own. Patient works in human resources at a local supermarket.
Exercises a couple times a week.
What data from the histories is important & RELEVANT;
therefore, it has clinical significance to the nurse?
RELEVANT Data from Present Problem:
Clinical Significance:
RELEVANT Data from Social History:
Clinical Significance:
What is the RELATIONSHIP of your patient’s past medical
history (PMH) and current meds?
3. (Which medication treats which condition? Draw lines to
connect.)
PMH:
Home Meds:
Pharm. Classification:
Expected Outcome:
HTN
Peripheral vascular disease (PVD)
Metoprolol (Lopressor) 50mg daily
Metformin 500mg daily
Cilostazol (Pletal)
II. Patient Care:
Most Recent VS:
WILDA Pain Assessment (5th VS):
T: (oral) 99o F
Words:
No Pain
4. P: 102
Intensity:
n/a
R: 22
Location:
n/a
BP: 174/104
Duration:
n/a
O2 sat: 96% on RA
Aggravate:
Alleviate:
n/a
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, visibly upset about diagnosis and lifestyle
changes.
RESP:
Breath sounds clear with equal aeration bilaterally
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),
neuro check: eyes open to speech, inappropriate words,
abnormal flexion, severe weakness left arm and severe
5. weakness left leg
GI:
Abdomen soft/nontender, bowel sounds audible per auscultation
in all four quadrants. BM this shift
GU:
Foley catheter with c/y/u
SKIN:
Erythema on buttocks and bilateral lower extremity with edema.
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:
Neuro checks
Monitor VS
Reinforce PT/OT recommendations
Evaluate anxiety
Turn and Repo q2
Educate about assistive devices (i/e- communication board)
Medical Management: Rationale for Treatment & Expected
Outcomes
Care Provider Orders:
Rationale:
Expected Outcome:
6. Labetalol 10mg IVP for systolic BP >160
Seizure precautions
Speech therapy
PT/OT
Neuro Checks q4hours
Continuous oxygen sat monitoring.
PRIORITY Setting: Which Orders Do You Implement First and
Why?
Care Provider Orders:
Order of Priority:
Rationale:
1.
2.
3.
4.
5.
6.
Medication Dosage Calculation:
Medication/Dose:
Mechanism of Action:
Volume/time frame to Safely Administer:
Nursing Assessment/Considerations:
Labatelol 10mg IVP prn, every 2 hours for systolic BP >160
7. Acetaminophen (Tylenol) 650mg PO, prn every 4 hours for
temp> 101.4oF
Radiology Reports:
What diagnostic results are RELEVANT that must be
recognized as clinically significant to the nurse?
RELEVANT Results:
Clinical Significance:
CT w/o contrast
Lab Results:
Complete Blood Count (CBC:)
Current:
High/Low/WNL?
WBC (4.5–11.0 mm 3)
4.6
Hgb (12–16 g/dL)
13
Platelets (150-450 x103/µl)
12. DeVry University
College of Engineering and Information Sciences
NETW310
Professor Lynn Risley
February 20, 2021
Table of Contents:
1. XYZ company Network
profile…………………………………… 3
2. Step One: Introduction
…………………………………………… 4
3. Step Two: Problems and
Solution
s ……………………………….. 4
4. Step Three: Pros and Cons
………………………………………. 6
5. Step Four:
Conclusion…………………………………………….. 9
6. References…………………………………………………………
10
7. Appendixes ………………………………………………………
13. 11
Lab Group Project
NETW310 Project: Troubleshooting Network Problems
You are hired by XYZ corporation to improve the efficiency and
reliability of their current network. Based on the information
given below , your team should make 3 recommendations to
improve their network.
The following is a short list (not complete) of the details you
recorded during your audit.
XYZ has 1500 employees spread over 2 adjacent 4 story
buildings built in 1984. The wiring in the building (and
between the two buildings) is cat5.
The backbone segment run between buildings is 212 feet.
Each building is 4500 square feet per floor.
The wireless LAN on the fourth floor of building two is
supported by two wireless 802.11g routers only.
The devices used in the local area network are a mixture of
10/100 switches and hubs.
The second floor of building one is networked by two 24 port
hubs.
14. Someone on the fourth floor of building one has installed their
own wireless router.
The second floor of building two has 3 24 port switches with
one router wired between switches 3 and 4. Switch 4 is the one
connected to the backbone for that floor.
STEP 1
INTRODUCTION
indication of 3 problems supported by the audit details that you
believe indicates there is a problem.
(be sure to indicate WHY you believe each one is a problem)
The first problem is the XYZ corporation is using cat 5 cablings
between their buildings. Cat5 cabling is outdated and too slow
for any corporation to run efficiently. Cat5e or higher should be
used for faster bandwidth and faster communication (Anders,
2019). Secondly, with the 1,500 employees the WIFI usage and
set up is outdated and too slow for a business. The number of
routers is not sufficient combined with the obsolete 802.11g
routers on the fourth floor of the second building presents a risk
to the integrity of the network security. Thirdly, the usage of
hubs, which are not reliable when it comes to sending packets
because of packet collisions, needs to be replaced with
switches. Finally, the usage of a personally installed router on
the fourth floor in building one, on the company network is a
high-risk issue and needs to be removed.
15. STEP 2
Indicate at least 2 possible solutions to each of the 3 problems
you have found.
-PROBLEM 1
The old Cat5 cabling connecting offices and floors is not
sufficient for more than 100 feet, bandwidth is 100MHz with
speeds of only 100 Mbps. (Anders, 2019)
-P1 solution 1.
Installing a fiber-optic between the two adjacent buildings will
improve bandwidth and speed for all 1,500 employees and
increase network security. This will also keep the corporation
current and ready for any technological advancements soon.
-P1 solution 2.
Upgrading the Cat5 wiring to Cat5e, Cat6, Cat6a or higher is
more reliable and provides better bandwidth and speeds. Also,
with each upgrade in a wire is less chance of cross-talk, with it
almost eliminated in the 6a. (Anders, 2019)
-PROBLEM 2
As the building was constructed in 1984, there will be multiple
interferences as well as dead spots or locations where the signal
is very poor. In building two on the fourth floor 2 wireless
802.11g routers are being utilized for the whole floor
operations. The 802.11g wireless routers are obsolete and lack
the bandwidth needed to support increasing device densities and
16. application requirements. ("Why an Obsolete Wireless Network
Is Bad for Business | SSD Technology Partners|Managed IT
Services", 2018)Thus, the use of 802.11g is not the best option
for the company’s needs.
-P2 solution 1.
Upgrading all routers and gateways to 3.1 Docsis and 802.11ac
or 802.11b to support higher bandwidth, range, and will provide
5Ghz to wireless users. ("All About DOCSIS 3.1 and DOCSIS
3.1 Cable Modems - Pick My Modem", 2019) Each floor has
4,500sqft of space, so at least two wireless routers will need to
be installed on each floor if a wireless operation is a way the
company is moving forward. Furthermore, the an immediate
disconnect of the router on the fourth floor in building one. It is
not a company-assigned router and causes a security threat to
the network and the company’s assets.
-P2 solution 2.
Running Cat5e or better cabling up to the fourth floor on each
building to eliminate the use of wireless routers and install
more switches.
-PROBLEM 3
The second floor in building one currently networks with two 24
port Hubs. Hubs can only work in half-duplex mode meaning
they can only send or receive data at any one time. It shares the
bandwidth between every device attached to the Hub, which
slows down the network. Hubs also send the message to every
17. computer connected to the Hub which can cause traffic issues if
another computer is trying to send a message as one is being
received. For this reason, Hubs have been replaced with
switches and routers. (Stone, 2021)
-P3 solution 1.
Upgrading to 10/100/1000 Switches since it supports higher
speed, and it is more reliable and efficient.
-P3 solution 2.
Upgrading to 10/100/1000 Switches and Docsis 3.1 routers.
While this will increase the connection to everyone it does also
open the business network to the outside world and leaves it
more open to malware and threats.
STEP 3
indicate the pros and cons for each possible solution for ea ch of
the 3 problems.
-PROBLEM 1
The old Cat5 cabling connecting offices and floors is not
sufficient for more than 100 feet, bandwidth is 100MHz with
speeds of only 100 Mbps. (Anders, 2019)
-P1 solution 1.
Installing fiber-optic cabling between the two adjacent
buildings.
18. Pros
· Increased bandwidth
· Security
· Fastest Speeds
· Near elimination of crosstalk
· More reliable
· Ready for future network advancements
Cons
· Price
· Delicate Wire
· Fiber Fuse (Appendix B)
· Unidirectional Light Propagation (Appendix C)
("The Pros and Cons of Fiber Optics | Fiber Optics vs. Copper
Wiring", 2021)
-P1 solution 2.
Installing Cat5e or better cabling.
Pros
Cat 5e
· 100 MHz Bandwidth
· 1,000 Mbps Speed
Cat 6
· 250 MHz Bandwidth
· 1,000 Mbps Speed
19. · STP – to reduce crosstalk
Cat 6a
· 500 MHz Bandwidth
· 10,000 Mbps Speed
· Shielding design to nearly eliminate crosstalk
Cat 7
· Latest Gen
· 600 MHz Bandwidth
Cat 7a
· 1,000 MHz Bandwidth
Cons
Cat 5e
· Lowest cost but not the fastest or best bandwidth for a
company’s needs.
Cat 6
· Other components need to be up to the speed of Cat6 to get the
desired speed
Cat 7
· Only slightly higher Bandwidth
· One of the most expensive
Cat 7a
· The most expensive out of Cat wiring
(Anders, 2019)
20. -PROBLEM 2
The usage of 802.11g wireless routers on the fourth floor of
building two.
-P2 solution 1.
Upgrading all routers and gateways to 3.1 Docsis and 802.11ac
or 802.11b to support higher bandwidth, range, and will provide
5Ghz to wireless users.
Pros
· Speed
· Quality of Service
· Higher Capacity on Existing Networks
· Energy Efficient
("All About DOCSIS 3.1 and DOCSIS 3.1 Cable Modems - Pick
My Modem", 2019)
Cons
· Security
· Cost
· Monitor Employees Usage
-P2 solution 2.
Run Cat5e or better cabling up to the fourth floor on each
building to eliminate the use of wireless routers and install
more switches.
21. Pros
· Wired Connected Devices
· Faster in a LAN setting than a router
Cons
· Cost
· Restricted to wired network connection
-PROBLEM 3
The usage of Hubs on the second floor of building one.
-P3 solution 1.
Upgrading to 10/100/1000 Switches since it supports higher
speed, and it is more reliable and efficient.
-P3 solution 2.
Upgrading to 10/100/1000 Switches and Docsis 3.1 routers.
While this will increase the connection to everyone it does also
open the business network to the outside world and leaves it
more open to malware and threats.
STEP 4
State your choice of the best solution for each of the three
problems and be sure to indicate why you believe that is the
best solution.
Problem one consisted of outdated and insufficient cabling for
the needs of the XYZ Corporation. Our advice is since new
cabling is needed, to replace it with the best option of Fiber
22. Optic Cable. While this is going to be an expense the reward is
far outweighing. Not only will the speeds and bandwidth be
superior the company will be ready for any advances in
technology to stay at the forefront against the competition.
Concerning problem two and the usage of the outdated 802.11g
router on floor four of building two, our advice is to upgrade all
wireless routers. Upgrading all the router and gateways to 3.1
Docsis and 802.11ac or 802.11b will support higher bandwidth,
range, and it will provide 5Ghz speeds.
Finally, in problem three the usage of Hubs is outdated and
inefficient. It slows down the network and congests the network
lines causing packets to be dropped and lost in transit. Our
advice on this issue is to remove the Hubs that are on the
second floor of building one and replace them with 10/100/1000
switches that are better able to handle the demands of the XYZ
Corporation.
In conclusion, we also feel it would be best to remove the
wireless router an employee has installed on floor four of
building one. This is a security risk and not worth the risk to the
corporation or your customers if data is lost or stolen.
By setting up the XYZ Corporation with Fiber Optic cabling,
upgrading all the wireless routers, and removing the Hubs, and
replacing them with Switches on every floor will improve the
23. network, connectivity, and make monitoring the network more
streamlined and flow more efficiently. With the latest
technology speeds and bandwidths, the XYZ Corporation will
be able to advance into the leaders of tomorrow.
References
All About DOCSIS 3.1 and DOCSIS 3.1 Cable Modems - Pick
My Modem. Pick My Modem. (2019). Retrieved 17 February
2021, from https://pickmymodem.com/all-about-docsis-3-1-and-
docsis-3-1-cable-modems/#:~:text=Service%20and%20Modems-
,What%20is%20DOCSIS%203.1%3F,Over%20Cable%20Service
%20Interface%20Specification.&text=DOCSIS%203.1%20supp
orts%20blazing%20speeds,connection%20up%20until%20this%
20point.
Anders, D. (2019). Uncovering Which Ethernet Cord Is Right
for You - Allconnect. Allconnect. Retrieved 17 February 2021,
from https://www.allconnect.com/blog/what-ethernet-cord-do-
you-need.
Stone, D. (2021). What Are the Disadvantages of Using Hubs?.
Small Business - Chron.com. Retrieved 17 February 2021, from
https://smallbusiness.chron.com/disadvantages-using-hubs-
72951.html.
24. The Pros and Cons of Fiber Optics | Fiber Optics vs. Copper
Wiring. Fieldnation.com. (2021). Retrieved 17 February 2021,
from https://www.fieldnation.com/insights/pros-and-cons-of-
fiber-optics.
Why an Obsolete Wireless Network Is Bad for Business | SSD
Technology Partners|Managed IT Services. SSD Technology
Partners|Managed IT Services. (2018). Retrieved 17 February
2021, from https://www.ssdel.com/wlan/why-an-obsolete-
wireless-network-is-bad-for-business/.
Appendices
Appendix A
Why an Obsolete Wireless Network Is Bad for Business
“The Wi-Fi technology that forms the basis of the WLAN is
advancing rapidly to keep up with these demands. If your
WLAN is based upon the 802.11g or older protocol, it is
obsolete and needs to be upgraded. Even 802.11n networks may
lack the bandwidth needed to support increasing device
densities and application requirements. Simply put, if your
WLAN is more than a few years old it is probably time for a
25. refresh.” ("Why an Obsolete Wireless Network Is Bad for
Business | SSD Technology Partners|Managed IT Services",
2018)
Appendix B
Pros and Cons of Fiber Optics
Fiber Fuse: At high power, fiber optic networks are also
susceptible to something known in the industry as “fiber fuse”.
This occurs when too much light meets with an imperfection in
the fiber. This occurrence can destroy long lengths of cable in a
short amount of time. ("The Pros and Cons of Fiber Optics |
Fiber Optics vs. Copper Wiring", 2021)
Appendix C
Pros and Cons of Fiber Optics
Unidirectional Light Propagation: Fiber cables are also limited
in the sense that they can only propagate light in one direction.
If bidirectional communication is a necessary part of
information transmission within a network, two concurrent
cables must be laid to achieve bidirectional propagation of
information. ("The Pros and Cons of Fiber Optics | Fiber Optics
vs. Copper Wiring", 2021)
NETW310 Week 7 Lab: Troubleshooting Network Problems
To complete your project you must 3 find network problems
based on the network audit details given and then provide your
26. solution with an explaination of why that is your
recommendation.
Create your video report and submit it to the Week 7 Dropbox
by the due date. Use the reference documents and websites as
required to complete this project.
In order to be eligible to receive full credit, you must include
sufficient content to cover the following:
· You need to provide 3 main problems that you see.
· You must provide at least 2 ways to fix each problem and
explain the pros and cons of each fix.
· You must state your recommend solution (from the ones you
indicated) and explain why that is your recommended solution.
· Conclusion to include your recap.
You are hired by XYZ corporation to improve the efficiency and
reliability of their current network. Based on the information
given below , your team should make 3 recommendations to
improve their network.
The following is a short list (not complete) of the details you
recorded during your audit.
XYZ has 1500 employees spread over 2 adjacent 4 story
buildings built in 1984. The wiring in the building (and
between the two buildings) is cat5.
The backbone segment run between buildings is 212 feet.
Each building is 4500 square feet per floor.
27. The wireless LAN on the fourth floor of building two is
supported by two wireless 802.11g routers only.
The devices used in the local area network are a mixture of
10/100 switches and hubs.
The second floor of building one is networked by two 24 port
hubs.
Someone on the fourth floor of building one has installed their
own wireless router.
The second floor of building two has 3 24 port switches with
one router wired between switches 3 and 4. Switch 4 is the one
connected to the backbone for that floor.
The following information came from capturing packets on the
XYZ network with wireshark.
(be sure to support your recommendations)
NETW310 Project: Troubleshooting Network Problems
You are hired by XYZ corporation to improve the efficiency and
reliability of their current network. Based on the information
given below , your team should make 3 recommendations to
improve their network.
28. The following is a short list (not complete) of the details you
recorded during your audit.
XYZ has 1500 employees spread over 2 adjacent 4 story
buildings built in 1984. The wiring in the building (and
between the two buildings) is cat5.
The backbone segment run between buildings is 212 feet.
Each building is 4500 square feet per floor.
The wireless LAN on the fourth floor of building two is
supported by two wireless 802.11g routers only.
The devices used in the local area network are a mixture of
10/100 switches and hubs.
The second floor of building one is networked by two 24 port
hubs.
Someone on the fourth floor of building one has installed their
own wireless router.
The second floor of building two has 3 24 port switches with
one router wired between switches 3 and 4. Switch 4 is the one
connected to the backbone for that floor.
STEP 1
Introduction
indication of 3 problems supported by the audit details that you
believe indicate there is a problem.
(be sure to indicate WHY you believe each one is a problem)
29. STEP 2
Indicate at least 2 possible solutions to each of the 3 problems
you have found.
-problem 1
-P1 solution 1.
-P1 solution 2.
-problem 2
-P2 solution 1.
-P2 solution 2.
-problem 3
-P3 solution 1.
-P3 solution 2.
STEP 3
indicate the pros and cons for each possible solution for each of
the 3 problems.
-problem 1
-P1 solution 1.
pros
cons
-P1 solution 2.
pros
cons
-problem 2
-P2 solution 1.
30. pros
cons
-P2 solution 2.
pros
cons
-problem 3
-P3 solution 1.
-P3 solution 2.
STEP 4
State your choice of the best solution for each of the three
problems and be sure to indicate why you believe that is the
best solution.
Medical/ Surgical Simulation: Cancer
Student Learning Objectives:
SLO’s 1-8
9
10. Provide education specific to patients with Cancer.
11. Implement interventions for a patient on neutropenic
31. precautions.
I
Preparation for scenario:
Pearson – Cellular Regulation
Module 16.M
Module 2 and 2C
Cancer Simulation Student Worksheet
I. Data Collection
History of Present Problem: Julie Hammel, a 58 year old
female, has just undergone chemotherapy and radiation therapy
for stage II Breast Cancer, currently on Tamoxofen.
Patient presents to her oncologist’s office with lymphedema,
was admitted to the hospital for monitoring.
PMH: Gravida 2; Para 2; full term uncomplicated vaginal
deliveries. Breast Cancer with right mastectomy. No known
allergies.
Personal/Social History: Married for 28 years. Has two adult
children. Works as a dental hygienist part time.
32. What data from the histories is important & RELEVANT;
therefore it has clinical significance to the nurse?
RELEVANT Data from Present Problem:
Clinical Significance:
- Stage II Breast Cancer
- Right Mastectomy
- Lymphedema
- Tamoxifen
RELEVANT Data from Social History:
Clinical Significance:
II. Patient Care Begins:
33. Current VS:
T: (oral) 99.0
P: (regular) 84
R: (regular) 14
BP:114/64
O2 sat:97% on RA
Pain:0/10
What VS data is RELEVANT that must be recognized as
clinically significant to the nurse?
RELEVANT VS Data:
Clinical Significance:
Current Assessment:
34. GENERAL APPEARANCE:
Resting comfortably, appears in no acute distress
RESP:
Breath sounds clear with equal aeration bilaterally, nonlabored
respiratory effort
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/nontender, bowel sounds audible per auscultation
in all four quadrants
GU:
Voiding without difficulty, urine clear/yellow
SKIN:
Unremarkable except for slight erythema in right upper
extremity due to external radiation. RUE edema.
Skin intact.
What assessment data is RELEVANT that must be recognized as
clinically significant to the nurse?
RELEVANT Assessment Data:
Clinical Significance:
35. Unremarkable.
Patient needs to be prepared for limited contact with visitors
and health care personnel for neutropenic precautions.
Needs teaching about importance of neutropenia and
lymphedema.
What interventions will you initiate based on this priority?
Nursing Interventions:
Rationale:
Foley output
Limit Visitors
Monitor Skin
Neurtropenic Precautions
Risk of stroke with Tamoxifen
36. Medical Management: Rationale for Treatment & Expected
Outcomes
Care Provider Orders:
Rationale:
Expected Outcome:
Monitor neutrophils, temp and affected site (right arm)
Monitor skin
Limit Visitors
Monitor for signs and symptoms of stroke
I &O’s
39. 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 (4.5–11.0mm 3)
2.3
44. Jenna Taylor, 18 years old
Primary Concept
Mood and Affect
Interrelated Concepts (In order of emphasis)
1. Safety
2. Psychosis
3. Clinical Judgment
4. Communication
5. Collaboration
Depression/Overdose with Psychosis History of Present
Problem:
45. Jenna Taylor is an 18-year-old woman who is brought to the
emergency department by ambulance after she admitted to her
mother that she had taken a “handful” of
dextroamphetamine/amphetamine (Adderall) this morning. Mom
noted that there are 20 tablets missing. Jenna admits that she
has been hearing voices telling her that she is worthless and
would be better off dead. She denies visual hallucinations.
As the primary nurse explores these comments further, Jenna
states, “The devil is in the place! I can feel it! The voices are
telling me that I am going to hell forever.” Jenna appears
fearful, anxious and does not maintain eye contact. When she
briefly glances and looks your way, she appears to be looking
through you.
Personal/Social History:
She was hospitalized three weeks ago for depression and
suicidal ideation and was discharged ten days ago. Jenna lives
with her mother. Her parents were divorced 12 years ago. She
graduated from high school, has few close friends, and has no
current plans for her future.
What data from the histories is RELEVANT and has clinical
significance to the nurse?
RELEVANT Data from Present Problem:
Clinical Significance:
46. RELEVANT Data from Social History:
Clinical Significance:
What is the RELATIONSHIP of your patient’s past medical
47. history (PMH) and current meds?
(Which medication treats which condition? Draw lines to
connect.)
PMH:
Home Meds:
Pharm. Classification:
Expected Outcome:
Attention deficit hyperactivity disorder (ADHD) Depression
with psychosis Anxiety
1. Dextroamphetamine/amphetamine XR
20 mg PO daily
2. Clonazepam 0.5 mg PO BID
3. Bupropion HCL SR 100 mg PO BID
One disease process often influences the development of other
illnesses. Based on your knowledge of
pathophysiology, (if applicable), which disease likely developed
FIRST, then initiated a “domino effect” in Jenna’s life?
48. · Circle the PMH problem that likely started FIRST.
· Underline at PMH problem(s) FOLLOWED as domino(s).
Patient Care Begins:
Current VS:
WILDA Pain Assessment (5th VS):
T: 99.2 F (37.3 C)oral
Words:
Denies
P: 92 (regular)
Intensity:
R: 20 (regular)
Location:
BP: 118/70
Duration:
O2 sat: 98% RA
Aggravate: Alleviate:
What VS data is RELEVANT and must be recognized as
clinically significant by the nurse?
RELEVANT VS Data:
Clinical Significance:
49. Current Assessment:
GENERAL
APPEARANCE:
Appears comfortable, no acute distress
RESP:
Breath sounds clear with equal aeration bilaterally, nonlabored
respiratory effort
CARDIAC:
Pink, warm and dry, no edema, heart sounds regular with no
abnormal beats, pulses strong, equal with palpation at
radial/pedal/post-tibial landmarks
NEURO:
Alert and oriented to person, place, time, and situation (x4), flat
affect
GI:
Abdomen soft/nontender, bowel sounds audible per auscultation
in all four quadrants
GU:
Voiding without difficulty, urine clear/yellow
50. SKIN:
Skin integrity intact
What assessment data is RELEVANT and must be recognized as
clinically significant by the nurse?
RELEVANT Assessment Data:
Clinical Significance:
Mental Status Examination (MSE):
APPEARANCE:
Dressed in casual clothes, no make-up; no body odor; appears
tired and appears stated age; cooperative during interview
MOTOR BEHAVIOR:
Psychomotor agitation, restless
SPEECH:
Speech is rapid, pressured
MOOD/AFFECT:
Appears anxious/fearful
THOUGHT PROCESS:
Illogical and not linear (thoughts do NOT make sense and are
51. disorganized
THOUGHT CONTENT:
Evidence of psychotic thinking and loss of contact with reality.
States, “The devil is in the place! I can feel it! The voices are
telling me that I am going to hell forever.” Hearing voices
telling her that she is worthless and would be better off dead.
PERCEPTION:
Auditory hallucinations present
INSIGHT/JUDGMENT:
Does not have insight, judgment is impaired
COGNITION:
Alert and Oriented x3, has difficulty concentrating
INTERACTIONS:
Has been isolating from friends and family over the last two
days
SUICIDAL/HOMICIDAL:
Denies homicidal thoughts, is currently suicidal, and acted on
this ideation by taking overdose of medication.
What MSE assessment data are RELEVANT and must be
interpreted as clinically significant by the nurse?
RELEVANT Assessment Data:
Clinical Significance:
52. Lab Results:
What lab results are RELEVANT and must be recognized as
clinically significant by the nurse?
Complete Blood Count (CBC:)
Current:
High/Low/WNL?
WBC (4.5–11.0 mm 3)
5.2
Hgb (12–16 g/dL)
14.2
Platelets (150-450 x103/µl)
229
Neutrophil % (42–72)
53. 58
What lab results are RELEVANT and must be recognized as
clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:
Basic Metabolic Panel (BMP:)
Current:
High/Low/WNL?
Sodium (135–145 mEq/L)
140
Potassium (3.5–5.0 mEq/L)
3.6
56. Clinical Significance:
Clinical Reasoning Begins…
1. What is the primary problem that your patient is most likely
presenting with?
2. What is the underlying cause/pathophysiology of this
concern?
Collaborative Care: Medical Management
Care Provider Orders:
Rationale:
Expected Outcome:
Acetaminophen level
Salicylate level
57. Complete blood count
(CBC)
Basic metabolic panel
(BMP)
Urine drug screen
Urine pregnancy
Establish peripheral IV
Diazepam 5 mg IV PRN for seizure activity
1:1 watch
Check for items of harm
Cardiac monitor
58. PRIORITY Setting: Which Orders Do You Implement First and
Why?
Care Provider Orders:
Order of Priority:
Rationale:
Establish peripheral IV
1:1 watch
Check for items of harm
Cardiac monitor
Collaborative Care: Nursing
3. What nursing priority(s) will guide your plan of care? (if
more than one-list in order of PRIORITY)
4. What interventions will you initiate based on this priority?
60. 7. What nursing assessments will identify this complication
EARLY if it develops?
8. What nursing interventions will you initiate if this
complication develops?
9. What psychosocial needs will this patient and/or family
likely have that will need to be addressed?
10. How can the nurse address these psychosocial needs?
Evaluation: Two hours later…
Jenna has become more restless with increased pacing in room.
She cries out loudly in a shriek. As the nurse enters the room,
Jenna is sitting on the bed and states fearfully, “I told you the
devil is in this place! Please help me!” She suddenly becomes
unresponsive, her body becomes rigid and she begins to have
61. rhythmic tonic/clonic movements of her entire body.
Current VS:
Most Recent:
Current WILDA:
T: 99.8 F (37.6 C) oral
T: 99.2F (37.3 C) oral
Words:
Denies
P: 140(regular)
P: 92 (regular)
Intensity:
R: 24
R: 20(regular)
Location:
BP: 158/90
BP: 118/70
Duration:
O2 sat: unable to obtain
O2 sat: 98% RA
Aggravate: Alleviate:
62. Current Assessment:
GENERAL
APPEARANCE:
Rigid body posture
RESP:
Loud, snoring respirations, oral secretions bubbling out of
mouth
CARDIAC:
Pale, warm and dry, no edema, heart sounds regular with no
abnormal beats, pulses strong, equal with palpation at
radial/pedal/post-tibial landmarks
NEURO:
Unresponsive, tonic/clonic movements lasted 60 seconds and
have now stopped, lethargic, not responsive to verbal commands
GI:
Abdomen soft/nontender, bowel sounds audible per auscultation
in all four quadrants
GU:
n/a
SKIN:
Skin integrity intact
1. What clinical data is RELEVANT that must be recognized as
clinically significant?
63. RELEVANT VS Data:
Clinical Significance:
RELEVANT Assessment Data:
Clinical Significance:
2. Has the status improved or not as expected to this point?
3. Does your nursing priority or plan of care need to be
modified in any way after this evaluation assessment?
64. 4. Based on your current evaluation, what are your nursing
priorities and plan of care?
Jenna is going to be admitted to intensive care for close
assessment and monitoring. Effective and concise handoffs are
essential to excellent care and if not done well can adversely
impact the care of this patient. You have done an excellent job
to this point, now finish strong and give the following SBAR
report to the nurse who will care for this patient:
Situation:
Name/age:
BRIEF summary of primary problem:
Background:
Primary problem/diagnosis:
RELEVANT past medical history:
Assessment:
Most recent vital signs:
65. RELEVANT body system nursing assessment data:
RELEVANT lab values:
How have you advanced the plan of care?
Patient response:
INTERPRETATION of current clinical status
(stable/unstable/worsening):
Recommendation:
Suggestions to advance the plan of care:
.
Education Priorities/Discharge Planning
1. What will be the most important discharge/education
priorities you will reinforce with her medical condition to
prevent future readmission with the same problem?
66. 2. What are some practical ways you as the nurse can assess the
effectiveness of your teaching with this patient?
Caring and the “Art” of Nursing
1. What is the patient likely experiencing/feeling right now in
this situation?
2. What can you do to engage with this patient’s experience,
and show that she matters to you as a person?
68. 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
69. 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:
71. 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
72. 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:
