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PRIORITY Patient Activity Part I: Who does the nurse see first?

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Herbie Saunders, 62 years old David Mueller, 71 years old Gladys Parker, 92 years old

CHF Exacerbation Below-the-Knee Amputation Weakness and Falls

NCLEX Client Need Categories Percentage of Items from Each

Category/Subcategory

Covered in

Case Study Safe and Effective Care Environment

✓ Management of Care 17-23% ✓

✓ Safety and Infection Control 9-15%

Health Promotion and Maintenance 6-12% ✓

Psychosocial Integrity 6-12%

Physiological Integrity

✓ Basic Care and Comfort 6-12%

✓ Pharmacological and Parenteral Therapies 12-18%

✓ Reduction of Risk Potential 9-15% ✓

✓ Physiological Adaptation 11-17% ✓

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Part I-Patient Care Scenarios

NOC Nurse Report Patient #1: Herbie Saunders

Patient Report: What Do You Notice? Clinical Significance:

“Herbie Saunders is a 62-year-old male who came in last

night for a CHF exacerbation. His doctor is Dr. Davis

and he’s a full code. He’s alert and oriented and can

make his needs known. He’s on tele, normal sinus

rhythm with occasional PVCs. His pressures are fine,

heart rate is in the 70s. Lungs are clear in the uppers with

crackles in the bases.

He’s coughing up a small amount of white frothy

secretions. He’s been on room air since he arrived,

oxygen sats are in the low-mid 90s. He got 40 mg IV

Lasix last night in the ED; I think you might have

something scheduled during your shift but I haven’t

given anything overnight. He has a 20 gauge in his right

forearm. I’m not sure how he gets around since he’s been

in bed since he got here.”

Most Recent Vital Signs @ 0357 What Do You Notice? Clinical Significance:

T: 98.6 F (oral)

P: 76

R: 20

BP: 128/87 (MAP 101 mmHg)

O2 sat: 92% on room air

Pain: denies

Admission Weight: 196 lb (89.1 kg)

In one sentence, describe the ESSENCE of the patient scenario that will guide your plan of care?

What questions do you have for the nurse?

You are the RN on a busy medical-surgical/telemetry floor at Anytown General

Hospital. Each nurse on your unit typically cares for 3-5 patients.

You have just arrived for your day shift and are receiving nurse-to-nurse reports

from three different night shift nurses. After you receive reports, you will have

an opportunity to review the current orders for each of your patients.

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Review Current Orders Patient #1: Herbie Saunders

Vital Signs: Q4H with telemetry and continuous pulse oximetry

Weight: Daily

I&O: Strict I&O Q8H

General Orders: Supplemental oxygen to keeps sats >90%

Fingerstick blood glucose QID

Hypoglycemia protocol (includes PRN orders for glucose and dextrose)

Activity: ad lib

Diet: 2gm Na

Notify MD if temp >100.4, HR <40 or >120, RR <8 or >26, BP <90 or >180 or O2 <90%

sustained with supplemental oxygen

Medications: 0800

0900

1200

1300

insulin aspart per sliding scale subq TID with meals

aspirin 81 mg PO daily

lisinopril 5 mg PO daily

metoprolol 25 mg PO BID

insulin glargine 20 units subq daily

furosemide 40 mg IV push BID

insulin aspart per sliding scale subq TID with meals

saline flush 10 ml IV TID

furosemide 40 mg IV push BID

Diagnostics: Echocardiogram, on-call

BMP + Mg, drawn but not yet resulted

Complete Blood Count (CBC) – Yesterday @1730

WBC HGB Hct PLTs

7.9 13.4 45 186

Basic Metabolic Panel (BMP) + Mg – Yesterday @ 1730

Na K Cl CO2 BUN Creat. Gluc Mg

141 3.6 103 26 16 1.1 132 2.0

Basic Metabolic Panel (BMP) + Mg – Today @ 0530

Na K Cl CO2 BUN Creat. Gluc Mg

collected collected collected collected collected collected collected collected

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NOC Nurse Report Patient #2: David Mueller

Patient Report: What Do You Notice? Clinical Significance:

“David Mueller is 72 years old, here for a right

BKA. He is Dr. Snyder’s patient. Vitals are fine,

he’s not on telemetry. Lungs are clear, he’s on

room air. I think he still has an 18 gauge in his left

a/c but I didn’t get a chance to flush it because he

was sleeping most of the night.

His finger sticks have been in the high 200s and he

gets a sliding scale. That’s really all I have for him.

I was so busy last night with a new admission and

another patient who was on the call light all night

long.”

Most Recent Vital Signs @ 0412 What Do You Notice? Clinical Significance:

T: 98.9 F (oral)

P: 96

R: 16

BP: 110/82 (MAP 91 mmHg)

O2 sat: 95% on room air

Pain: 2/10

Admission Weight: 202 lbs (91.8 kg)

In one sentence, describe the ESSENCE of the patient scenario that will guide your plan of care?

What questions do you have for the nurse?

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Review Current Orders

Patient #2: David Mueller

Vital Signs: Q8H, does not require telemetry or continuous oximetry

Weight: n/a

I&O: n/a

General Orders: Fingerstick blood glucose QID

Hypoglycemia protocol (includes PRN orders for glucose and dextrose)

Dressing change to be completed by orthopedic surgery team. If dressing is saturated, reinforce

and notify attending or on-call surgeon after hours.

Elevate right leg

Activity: with assistance, out of bed for meals

Diet: Diabetic 2 gm na

Notify MD if temp >100.4, HR <40 or >120, RR <8 or >26, BP <90 or >180 or O2 <90%

sustained with supplemental oxygen

Medications: 0800

0900

1200

1300

PRN

insulin aspart per sliding scale, subq TID with meals

acetaminophen 650 mg PO QID

amlodipine 10 mg PO daily

fluoxetine 20 mg PO daily

gabapentin 300 mg PO TID

insulin aspart per sliding scale, subq TID with meals

acetaminophen 650 mg PO QID

gabapentin 300 mg PO TID

saline flush 10 ml IV TID

oxycodone 5 mg Q6H PRN for pain,

Diagnostics: No new labs ordered today

Appointments: Physical Therapy at 0930

Occupational Therapy at 1400

Complete Blood Count (CBC) – Yesterday @0530

WBC HGB Hct PLTs

9.8 13.2 47 165

Basic Metabolic Panel (BMP) + Mg – Yesterday @ 0530

Na K Cl CO2 BUN Creat. Gluc Mg

140 4.1 104 28 10 0.9 224 2.1

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NOC Nurse Report Patient #3: Gladys Parker

Patient Report: What Do You Notice? Clinical Significance:

“Gladys Parker is a sweet little 92-year-old lady. She’s

here because she had a fall at her nursing home that

they think was due to dehydration and weakness. She

was admitted by the night float but Dr. Howard will

probably be her attending. She’s DNR/DNI. Alert to

self and place, but definitely disoriented to time and

situation. She’s really forgetful and doesn’t seem to

want to bother anyone so she hasn’t used her call light

all night. I’d guess she’s at least an assist of one for

transfers.

She’s on telemetry because her electrolytes were off

when she arrived. EKG showed Afib with a heart rate

in the 90s. Blood pressures are pretty soft, her systolic

blood pressures were in the low 90s for me. Lungs are

clear, she’s on room air. They put her on a mechanical

soft diet. She takes her pills whole in pudding or

applesauce. The nursing home said her last bowel

movement was 3 days ago and that she’s incontinent of

both bowel and bladder.

Her urine seems really concentrated and has a strong

odor. I noticed that there is still an outstanding order to

collect a UA but I couldn’t get one since she was

incontinent all night. Maybe you can address that with

the doctor today if they still want it. She’s got a 22

gauge in her left wrist with LR running at 100 mls/hr

for a total of one liter. I started that at 0200.”

Most Recent Vital Signs @0425 What Do You Notice? Clinical Significance:

T: 97.2 F (oral)

P: 92

R: 18

BP: 94/63 (MAP 73 mmHg)

O2 sat: 95% on room air

Pain: denies

Admission Weight: 117 lbs (53.2 kg)

In one sentence, describe the ESSENCE of the patient scenario that will guide your plan of care?

What questions do you have for the nurse?

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Review Current Orders

Patient #3: Gladys Parker

Vital Signs: Q4H with telemetry, does not require continuous oximetry

Weight: upon admission

I&O: n/a

General Orders: Activity: with assistance, out of bed for meals

Notify MD if temp >100.4, HR <40 or >120, RR <8 or >26, BP <90 or >180 or O2 <90%

sustained with supplemental oxygen

Medications: 0900

1300

Infusion

cholecalciferol 2000 units PO daily

docusate/senna 50/8.8 mg PO BID

donepezil 5 mg PO daily

metoprolol 12.5 mg PO BID

saline flush 10 ml IV TID

Lactated Ringer’s IV at 100 ml/hr for a total of one liter

Diagnostics: No new labs ordered today

Urinalysis/Urine Culture was ordered in ED but has not been collected

Physical Therapy consult pending

Occupational Therapy consult pending

Speech Therapy consult pending due to difficulty swallowing

Nutrition consult pending

Complete Blood Count (CBC) – Yesterday @2125

WBC HGB Hct PLTs

10.1 12.9 37 225

Basic Metabolic Panel (BMP) + Mg – Yesterday @ 2125

Na K Cl CO2 BUN Creat. Gluc Mg

144 3.3 103 23 19 1.4 93 1.5

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Priority Setting: Who Do You See First?

What order are you going to see/assess your patients? Why?

Order of Priority: Rationale:

What body system(s) will you assess most thoroughly based on the primary/priority problem? Identify top

three priority/focused assessments.

Patient #1:

PRIORITY Body System(s): PRIORITY Nursing Assessments:

Patient #2:

PRIORITY Body System(s): PRIORITY Nursing Assessments:

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Patient #3:

PRIORITY Body System(s): PRIORITY Nursing Assessments:

What order are you going to administer medications? Why?

Order of Priority: Rationale:

Your facility’s window for medication passes is within one hour of the scheduled time. Can you combine any

medication administrations to reduce the number of separate medication passes?

  1. Herbie Saunders 62 years old:
  2. NCLEX Client Need Categories:
  3. Safe and Effective Care Environment:
  4. Management of Care:
  5. Safety and Infection Control:
  6. 915:
  7. Health Promotion and Maintenance:
  8. Psychosocial Integrity:
  9. 612:
  10. Physiological Integrity:
  11. Basic Care and Comfort:
  12. 612_2:
  13. 1218:
  14. Reduction of Risk Potential:
  15. Physiological Adaptation:
  16. Patient Report:
  17. What Do You Notice:
  18. Most Recent Vital Signs 0357:
  19. What Do You Notice_2:
  20. Vital Signs:
  21. Q4H with telemetry and continuous pulse oximetry:
  22. Weight:
  23. Daily:
  24. IO:
  25. Strict IO Q8H:
  26. General Orders:
  27. Medications:
  28. insulin aspart per sliding scale subq TID with meals aspirin 81 mg PO daily lisinopril 5 mg PO daily metoprolol 25 mg PO BID insulin glargine 20 units subq daily furosemide 40 mg IV push BID insulin aspart per sliding scale subq TID with meals saline flush 10 ml IV TID furosemide 40 mg IV push BID:
  29. Diagnostics:
  30. Echocardiogram oncall BMP Mg drawn but not yet resulted:
  31. Patient Report_2:
  32. What Do You Notice_3:
  33. Most Recent Vital Signs 0412:
  34. What Do You Notice_4:
  35. Vital Signs_2:
  36. Q8H does not require telemetry or continuous oximetry:
  37. Weight_2:
  38. na:
  39. IO_2:
  40. na_2:
  41. General Orders_2:
  42. Medications_2:
  43. insulin aspart per sliding scale subq TID with meals acetaminophen 650 mg PO QID amlodipine 10 mg PO daily fluoxetine 20 mg PO daily gabapentin 300 mg PO TID insulin aspart per sliding scale subq TID with meals acetaminophen 650 mg PO QID gabapentin 300 mg PO TID saline flush 10 ml IV TID oxycodone 5 mg Q6H PRN for pain:
  44. No new labs ordered today:
  45. Appointments:
  46. Physical Therapy at 0930 Occupational Therapy at 1400:
  47. Patient Report_3:
  48. What Do You NoticeGladys Parker is a sweet little 92yearold lady Shes here because she had a fall at her nursing home that they think was due to dehydration and weakness She was admitted by the night float but Dr Howard will probably be her attending Shes DNRDNI Alert to self and place but definitely disoriented to time and situation Shes really forgetful and doesnt seem to want to bother anyone so she hasnt used her call light all night Id guess shes at least an assist of one for transfers Shes on telemetry because her electrolytes were off when she arrived EKG showed Afib with a heart rate in the 90s Blood pressures are pretty soft her systolic blood pressures were in the low 90s for me Lungs are clear shes on room air They put her on a mechanical soft diet She takes her pills whole in pudding or applesauce The nursing home said her last bowel movement was 3 days ago and that shes incontinent of both bowel and bladder Her urine seems really concentrated and has a strong odor I noticed that there is still an outstanding order to collect a UA but I couldnt get one since she was incontinent all night Maybe you can address that with the doctor today if they still want it Shes got a 22 gauge in her left wrist with LR running at 100 mlshr for a total of one liter I started that at 0200:
  49. Clinical SignificanceGladys Parker is a sweet little 92yearold lady Shes here because she had a fall at her nursing home that they think was due to dehydration and weakness She was admitted by the night float but Dr Howard will probably be her attending Shes DNRDNI Alert to self and place but definitely disoriented to time and situation Shes really forgetful and doesnt seem to want to bother anyone so she hasnt used her call light all night Id guess shes at least an assist of one for transfers Shes on telemetry because her electrolytes were off when she arrived EKG showed Afib with a heart rate in the 90s Blood pressures are pretty soft her systolic blood pressures were in the low 90s for me Lungs are clear shes on room air They put her on a mechanical soft diet She takes her pills whole in pudding or applesauce The nursing home said her last bowel movement was 3 days ago and that shes incontinent of both bowel and bladder Her urine seems really concentrated and has a strong odor I noticed that there is still an outstanding order to collect a UA but I couldnt get one since she was incontinent all night Maybe you can address that with the doctor today if they still want it Shes got a 22 gauge in her left wrist with LR running at 100 mlshr for a total of one liter I started that at 0200:
  50. Most Recent Vital Signs 0425:
  51. What Do You Notice_5:
  52. Clinical Significance:
  53. undefined:
  54. Vital Signs_3:
  55. Q4H with telemetry does not require continuous oximetry:
  56. Weight_3:
  57. upon admission:
  58. IO_3:
  59. na_3:
  60. General Orders_3:
  61. Medications_3:
  62. cholecalciferol 2000 units PO daily docusatesenna 5088 mg PO BID donepezil 5 mg PO daily metoprolol 125 mg PO BID saline flush 10 ml IV TID Lactated Ringers IV at 100 mlhr for a total of one liter:
  63. Diagnostics_2:
  64. Order of PriorityRow1:
  65. RationaleRow1:
  66. Order of PriorityRow2:
  67. RationaleRow2:
  68. Order of PriorityRow3:
  69. RationaleRow3:
  70. Patient 1:
  71. PRIORITY Body SystemsRow1:
  72. PRIORITY Nursing AssessmentsRow1:
  73. Patient 2:
  74. PRIORITY Body SystemsRow1_2:
  75. PRIORITY Nursing AssessmentsRow1_2:
  76. Patient 3:
  77. PRIORITY Body SystemsRow1_3:
  78. PRIORITY Nursing AssessmentsRow1_3:
  79. Order of PriorityRow1_2:
  80. RationaleRow1_2:
  81. Order of PriorityRow2_2:
  82. RationaleRow2_2:
  83. Order of PriorityRow3_2:
  84. RationaleRow3_2:
  85. Text10:
  86. Text11:
  87. Text12:
  88. Text13:
  89. Text14:
  90. Text15:
  91. Text16:

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