Doris Bowman Vsim 2 - vsim document PDF

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CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) Total Abdominal Hysterectomy Removal of the uterus and the cervix. It is a surgical procedure through an incision (vertically or horizontally to bikini line, 3-5 small incisions) in your lower abdomen. Bilateral Saplingo-oophorectomy Removes both ovaries and fallopian tubes. Total Hysterectomy and bilateral salpingo-oophorectomy Will be done during one procedure. Will remove the uterus, cervix, ovaries, and fallopian tubes. After a hysterectomy you will no longer haver periods or have the ability to get pregnant. These procedures are performed if the pt has a large uterus, has signs of disease on pelvic organs, to treat gynecologic cancer, uterine fibroids, uterine prolapse, abnormal vaginal bleeding, chronic pelvic pain or endometriosis. Or if pt is at high risk for ovarian cancer, have certain types of breast cancer or have ovarian masses or cysts.

DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS)





Cervial Cytology (pap test)- detects presence of abnormal cervical presence of abnormal cervical cells or cervical cancer. Endometric biopsyindicates if there are abnormal cells in the uterine lining or endometrial cancer

PATIENT INFORMATION Doris Bowman is a 39 year old female patient who underwent a total abdominal hysterectomy with bilateral salpingooopherectomy with general anesthesia. Pt was extubated in the OR and is breathing spontaneously at 21 breaths per minute. BP is stable at 154/92.

ANTICIPATED PHYSICAL FINDINGS

Vaginal bleeding/discharge Limited mobility Fatigued from general anesthesia Pain Discomfort in abdominal area Sutures or staples in incision area Constipation

ANTICIPATED NURSING Monitor for signs of pain Administer pain medication as needed/education on opioids Encourage pt to ambulate Monitor vital signs Assess incision site/Change dressing Foley care/pt education Assess for emotional stress Education on what to expect/what is normal after procedure Education on pain management Education on ROM exercises Education on home incision care Education on complications/when to call healthcare physician Assess IV site/tubing Incentive spirometer Education on diet

vSim ISBAR ACTIVITY WORKSHEET INTRODUCTION

STUDENT Hello, my name is Paola and I am the nurse taking care of patient in room 2 in the Nova Sim Lab. Am I speaking to ____?

Your name, position (RN), unit you are working on Doris Bowman is a 39 year old female patient who underwent a total abdominal hysterectomy with bilateral salpingoPatient’s name, age, specific reason for visit oopherectomy.

SITUATION

BACKGROUND Patient’s primary diagnosis, date of admission, current orders for patient

ASSESSMENT Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs

RECOMMENDATION Any orders or recommendations you may have for this patient

Patient was admitted on 05/20/2020. Current orders include morphine 2 mg IV push for pain as needed, ondansetron 4 mg IV push for nausea as needed per orders, naloxone 0.2 mg IV push every 2-3 minutes as needed per orders, potassium chloride in 5% dextrose and normal saline IV at 125 mL/hour.

Patient tolerated the procedure without complications. She has an abdominal incision covered with a 4 x 4 gauze dressing with no drainage noted. IV of potassium chloride in 5% dextrose and normal saline is infusing at 125 mL/hr/ Estimated blood loss was 400 mL. Prior to giving morphine, patient was breathing at 21 bpm. BP was stable at 154/92. HR: 103 bpm, SpO2: 94% and oral temp was 99 F. Pt has a normal skin turgor, cold and very sweaty. Once pt received morphine, pt developed respiratory depression. RR decreased to 5, HR: 90bpm, LOC: somnolent, BP: 125/73, oral temp: 99 F. Naloxone was given to reverse opioid overdose effecrs. Pt then went into a stable condition and vital signs were: BP: 120/68, HR: 94bpm, RR: 17, SpO2: 93% and oral temp 99 F. I recommend continuous monitoring of incision and IV site, management of pain, administer pain meds as needed, encourage deep breathing/coughing, patient education on early ambulation, risks of falls, and safety, provide comfort, assess pt’s foley catheter and I&O’s, have the call button within reach and provide education for pt and family on complications of procedure and use of opioids.

PHARM-4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE

MEDICATION: ondansetron

CLASSIFICATION: Antiemetics, selective serotonin receptor antagonists

PROTOTYPE: Zuplenz

SAFE DOSE OR DOSE RANGE, SAFE ROUTE Adults: 4 mg undiluted solution for injection IM or IV over 2 to 5 minutes at end of surgery. Or, 8 mg ODT or oral soluble film PO as a single dose 30 to 60 minutes before surgery.

PURPOSE FOR TAKING THIS MEDICATION To prevent nausea and vomiting from postop, radiation therapy in patients receiving total body irradiation, single high-dose fraction therapy to abdomen, or daily fractionated radiation therapy to abdomen, moderately emetogenic chemotherapy, and from highly emetogenic chemotherapy.

PATIENT EDUCATION WHILE TAKING THIS MEDICATION 1. ALERT: caution patient to contact HCP immediately for signs and symptoms of abnormal HR or rhythm, such as palpations, dyspnea, or dizziness. 2. Tell patient that an ECG may be necessary to monitor HR and rhythm. 3. Instruct pt to immediately report difficulty breathing after drug administration. 4. Tell patient receiving drug IV to report discomfort at insertion site.

PHARM-4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE

MEDICATION: morphine hydrochloride

CLASSIFICATION: Opioid analgesics, opioids, schedule II

PROTOTYPE: Doloral

SAFE DOSE OR DOSE RANGE, SAFE ROUTE Adults: Initially, 10 mg (based on 70 kg individual) IM or 0.1 to 0.2 mg/kg IV every 4 hours p.r.n. Or, 15 to 30 mg (immediate-release tablets) PO, or 10 to 20 mg (oral solution) PO, or 10 to 20 mg PR every 4 hours p.r.n.For extended-release tablet, give 15 or 30 mg PO every 8 to 12 hours.For epidural injection, give 5 mg by epidural catheter; then, if pain isn’t relieved adequately in 1 hour, give supplementary doses of 1 to 2 mg at intervals sufficient to assess effectiveness. Maximum total epidural dose shouldn’t exceed 10 mg/24 hours.For intrathecal injection, a single dose of 0.2 to 1 mg may provide pain relief for 24 hours (only in the lumbar area). Don’t repeat injections.

PURPOSE FOR TAKING THIS MEDICATION It is used to relieve moderate to severe pain but has a high addictive potential.

PATIENT EDUCATION WHILE TAKING THIS MEDICATION 1. BLACK BOX WARNING: caution pt or caregiver of pt taking an opioid with a benzodiazepine, CNS depressant, or alcohol to seek immediate medical attention for dizziness, light-headedness, extreme sleepiness, slowed or difficult breathing, or unresponsiveness. 2. Explain assessment and monitoring process to pt and family. Instruct them to immediately report difficulty breathing or other signs or symptoms of a potential adverse opioid related reaction. 3. Encourage pt to report all medications being taken, including prescription and OTC medications and supplements. 4. Warn pt that morphine can cause constipation. 5. WARN pt to immediately report signs and symptoms or serotonin syndrome, adrenal insufficiency and decreased sex hormone levels. 6. If give post op, encourage pt to turn, cough, deep breathe, and use incentive spirometer to prevent lung problems. 7. Assist patient while ambulating, while getting out of bed. 8. Instruct pt to not drink alcohol or take any drugs containing alcohol due to causing additive CNS

effects and potentially fatal overdose. 9. Educate pt to not crush, break, or chew, extended release forms.

PHARM-4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE

MEDICATION: naloxone hydrochloride

CLASSIFICATION: Antidotes, opioid antagonists

PROTOTYPE: Evzio, Narcan

SAFE DOSE OR DOSE RANGE, SAFE ROUTE Adults: 0.1 to 0.2 mg IV every 2 to 3 minutes, p.r.n. Repeat doses may be required within 1- or 2-hour intervals depending on amount, type (short- or long-acting), and time interval since last administration. Supplemental IM doses have produced a longer-lasting effect.

PURPOSE FOR TAKING THIS MEDICATION Can temporarily stop the effects of opioids drugs. It can help restore breathing during an opiod overdose.

PATIENT EDUCATION WHILE TAKING THIS MEDICATION 1. Reassure family that patient will be monitored closely until effects of opioid resolve. 2. Instruct patient and family about signs and symptoms of opioid toxicity emergency (unusual sleepiness or inability to awaken the person, breathing problems, pinpoint pupils). 3. Instruct patient and caregivers on the use of autoinjector and to seek emergency care as soon as possible when it’s used. Advise patient to refer to manufacturer’s instructions. 4. Instruct person who will be administering intranasal drug to read instructions carefully before use. Remind the person that the spray is single-use only; if signs and symptoms of an opioid emergency return and more drug is needed, a second container must be used. 5. Instruct person who will be administering intranasal drug to seek emergency help immediately after giving first dose of drug. 6. Instruct patient and caregivers that naloxone administration can precipitate acute opioid withdrawal symptoms, which can be fatal in neonates.

Clinical Worksheet Date: 05/23/2020 Initials: D.R

Student Name: Paola Ocampo

Age:

Diagnosis: Total Abdominal Hysterectomy

M/F: F

Length of Stay:

HCP: J DOE, Admitting

Isolation: Standard

Fall Risk: High Risk

Code Status:

Allergies:

Consults: PT, respiratory therapist, surgery

Transfer: Needs assistance

Assigned vSim: Doris Bowman IV Type: Peripheral Location: Right arm

Critical Labs: Low Hct and Hbg

Fluid/Rate: KCl in 5% dextrose and NS is infusing at 125 mL/hr

Other Services:

Consults Needed: Pain care specialist, post op surgery, PT, respiratory therapist

Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: Doris Bowman had a total abdominal hysterectomy with bilateral saplingoopherectomy. Health History/Comorbities (that relate to this hospitalization): Patient was diagnosed with uterine fibroids, dysmenorhhea and menorrhagia. She has a family history of uterine and ovarian cancer..

Shift Goals/ Patient Education Needs: 1. Acceptance of loss of the uterus 2. Absence of pain or discomfort 3. Increased knowledge of self care requirements (patient education!!) 4. Absence of complications Path to Discharge: Patient experiences decreased anxiety, reports relief of abdominal pain and discomfort while ambulating and at rest, verbalizes knowledge and understanding of self care such as practicing deep breathing, turning and leg exercises as instructed, increases activity and ambulation daily, reports adequate fluid intake and adequate urinary output, and absence of complications such as ambulating early to prevent further complications, reports no urinary problems or abdominal distention and exhibits normal vital signs.

Path to Death or Injury: Patient develops further complications such as VTE, infection, hemorrhage, or respiratory distress due to opioid overdose.

Alerts: What are you on alert for with this patient? (Signs & Symptoms)

Management of Care: What needs to be done for this Patient

1.

Pain management

Today? 1. Provide patient education

2.

Infection

2.

Administer pain medication, as needed.

3.

Monitor vital signs frequently

4.

Apply antiembolism stockings

5.

Provide comfort

6.

Encourage early ambulation/cough/deep breathing

3. Constipation What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?) 1.

Vital signs (assess intensity of pt’s pain)

2.

Assess dressing

3.

Auscultate bowel sounds

Priorities for Managing the Patient’s Care Today 1. VITAL SIGNS 2.

Pain management

List Complications that may occur related to dx, procedure, comorbidities:

3.

Patient education

1.

4.

Assess dressing/incision

Hemorrhage

2. VTE 3. Infection 4. Respiratory distress due to overdose on opioids

What nursing or medical interventions may prevent the above Alert or complications?

1.

Monitor vital signs

2.

Apply antiembolism stockings

3.

Encourage early ambulation

4.

Monitor sedation levels/respiratory rate

What aspects of the patient care can be Delegated and who can do it? The nurse is responsible for most of the care for this patient, although the nurse can delegate vital signs or if patient reports pain or is seen in discomfort, the CP can alert the nurse so they can assess patients pain. Nurses must do all post op assessments and cannot delegate this to anyone due to the fact that is very essential the patient is in stable condition and no complications occur throughout the time in the PACU. Although Ms. Bowman’s case requires a lot of attention from the nurse, the CP can provide comfort and provide safety for this patient when needed such as changing the bed sheets if the become soiled, give patient water/ice chips, or even providing a blanket.

Clinical Worksheet

Reflection Questions Paste your reflection questions in the box below 1. How did the scenario make you feel? - This scenario was very new to me, due to the fact that when we went to clinicals last semester I never experienced a code. I felt anxious but with the help of my colleagues I was able to do just fine. 2. What further intervention would have been required if naloxone hydrochloride (Narcan) had not been effective in this case? - Manual ventilation with the bag-valve mask with the oxygen connected to high flow rate would have been done to oxygenate the patient which prevents patient from becoming hypoxemic. 3. Discuss readiness for discharge from PACU criteria. - Indicators of recovery include stable blood pressure, adequate respiratory function, and adequate oxygen saturation level compared with baseline. 4. What key elements would you include in the handoff report for this patient? Consider the SBAR (situation, background, assessment, recommendation) format. - S: Dorris Bowman is a 39 year old patient who is post op from a total abdominal hysterectomy with bilateral salpingo-oophorectomy with general anesthesia. B: Patient was admitted on 05/20/2020. Current orders include morphine 2 mg IV push for pain as needed, ondansetron 4 mg IV push for nausea as needed per orders, naloxone 0.2 mg IV push every 2-3 minutes as needed per orders, potassium chloride in 5% dextrose and normal saline IV at 125 mL/hour. A: Patient tolerated the procedure without complications. She has an abdominal incision covered with a 4 x 4 gauze dressing with no drainage noted. IV of potassium chloride in 5% dextrose and normal saline is infusing at 125 mL/hr/ Estimated blood loss was 400 mL. Prior to giving morphine, patient was breathing at 21 bpm. BP was stable at 154/92. HR: 103 bpm, SpO2: 94% and oral temp was 99 F. Pt has a normal skin turgor, cold and very sweaty. Once pt received morphine, pt developed respiratory depression. RR decreased to 5, HR: 90bpm, LOC: somnolent, BP: 125/73, oral temp: 99 F. Naloxone was given to reverse opioid overdose effecrs. Pt then went into a stable condition and vital signs were: BP: 120/68, HR: 94bpm, RR: 17, SpO2: 93% and oral temp 99 F. R: I recommend continuous monitoring of incision and IV site, management of pain, administer pain meds as needed, encourage deep breathing/coughing, patient education on early ambulation, risks of falls, and safety, provide comfort, assess pt’s foley catheter and I&O’s, have the call button within reach and provide education for pt and family on complications of procedure and use of opioids. 5. What further complications could have occurred if the respiratory depression had not resolved? - Hypoxia, neurological damage, cardiac arrest, intubation of pt, and even death. 6. If Doris Bowman’s family members had been present during the scenario, describe how you would support them when her condition deteriorated. - As soon as the code is called, we ask the family members to step out the room so us, health care providers can do our job right and stabilize the patient. Afterwards, I will explain to them what occurred and why it happened. I will explain to them the risks of opiods but that they are very effective and we just have to monitor her more frequently. 7. What would you do differently if you were to repeat this scenario? How would your patient care change? - If I were to repeat this scenario, I would be approach the situation in a more calmly matter, even though I know the situation isn’t a calm, I would be more knowledgeable on what to do and what I shouldn’t do, such as making sure I assess the patients pain and asking her if she has any allergies PRIOR to administering morphine. Also, vital signs are very essential because we do not want to give a patient morphine if they their vital signs are not stable.

Clinical Judgement Components Scoring: Exemplary = 4 point Accomplished = 3 points Developing = 2 points Beginning = 1 point Score: vSim 1

Noticing: Focused Observation: Recognizing Deviations from Expected Patterns: Information Seeking:

Score: vSim 2

EAD B

3

EAD B EAD B

2 3

Total for category:

8

Interpreting: Prioritizing Data: Making Sense of Data:

EAD B EAD B

2 2

Total for category:

4

Calm, Confident Manner: EAD B Clear Communication: EAD B Well-Planned Intervention/Flexibility: EAD B Being Skillful EAD B

2 3

Total for category:

9

Responding:

2 2

Reflecting: Evaluation/Self-Analysis: EAD B Commitment to Improvement: E A D B

Total for category:

3 4

7

Score: vSim 2...