Narrative Documentation Simulation and Rubric copy PDF

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Summary

Simulation lab documentation exercise...

Description

SOUTH LOUISIANA COMMUNITY COLLEGE Associate Degree Nursing, TRACK II Document

Met

Not Met

1. A hypothetical “First Look” note: Describe what you see when entering the patient’s room the first time. 2. Hypothetical vital signs and additional assessments as needed. 3. The medication error: a. Resolve the error appropriately b. Document as appropriate on incident report 4. All hypothetical communication with the provider as appropriate. Note: The provider will NOT be issuing additional orders. 5. Administration of the following medications as appropriate. a. Lovenox b. Ampicillin c. Gentamycin d. Morphine PCA e. Additional prn pain medications post-PCA f. Additional prn medications of any kind. 6. Discontinuation of the foley catheter and PCA at the appropriate time. 7. Patient education, including but not limited to: a. Plan of care b. Pain management c. Incentive Spirometry d. Ambulation e. Expected patient actions following removal of foley catheter 8. Review of lab work and report to provider as appropriate. 9. Correct calculation of all intake and output. 10. An off-going shift note reflecting report and the relinquishment of care.

Met Create an SBAR for the next shift. (Multiple formats loaded. Choose one.) Use all supporting documentation (forms) as needed. Additional Instructor Comments

Additional Duties Not Met

Instructor Comments

Greene John Physician: Peterson Isolation Precautions: Allergies: None NKDA Service: Med-Surg

Age 64

Gender M

DOB 02/09/1954

Medical Record # 1234567890

Height: 69” 175.26cm Weight: 223lb 102.05 kg BMI: 33.2 Obese

Mr. Green was admitted yesterday to the hospital for a bowel resection with re-anastomosis secondary to colon cancer. He was admitted to the medical-surgical floor in stable condition at about 1500. Shift change came and went as usual. Mr. Green’s night shift assessment was WNL for someone s/p major abdominal surgery. Recovery was progressing uneventfully until 0400 at which time he spiked a temperature of 103.3. The night shift nurse called the physician, provided report and received new orders, all of which have been documented and acknowledged. Intake/output is totaled at 0600 and 1800. Whatever the amount is infused or taken PO or whatever amount left in the foley catheter (or the JP drain or the suction canister or the specipan or the bedside commode or …) between 0600 and 0700 or 1800 and 1900 is for the next shift, the oncoming shift, to include in their fluid count. The RN hung a new bag of fluids and the first antibiotic at 0600; the tech emptied the foley catheter at that time thus closing out the night shift’s I and O documentation. The administration of new bag and antibiotics is documented on the night shift MAR. The infusion of fluids and any urine collected between 0600 and 1800 is yours to count. You came on shift and received report at 0645. Your unit was short two nurses so your patient assignment was an exceedingly heavy eight patients. Even the charge nurse has a half load of four patients in addition to her other duties. No tech and no unit secretary were scheduled for today which means you are down by a total four staff members. You performed your head-to-toe assessment at 0730 and were able to document same below. FYI: It is not necessary to re-document the shift assessment in narrative notes unless you just adore double charting. The day went downhill from there. Everything you did during the shift other than the assessment is written on hypothetical post-it notes or scraps of paper towel tucked into your pockets. It's 7PM and you have given report to night shift. Your greatest desire is to go home to a hot bath and your favorite alcoholic product, not necessarily in that order. But you must first document 12 hours of patient care … so … you take your first bathroom break of the day and grab a cookie and a coke. You sit down to document in the EMR and you realize that the hospital-wide EMR has crashed. Can this day get any worse? You wonder why you gave up your lucrative position as a telemarketer to become a nurse. You’re threatening to quit and become a Wal-Mart greeter. Review the chart carefully and thoroughly. Consider the report you received this morning. All orders are correct. Using orders and time cues contained within the patient chart pick up the scattered pieces of your day and narratively document your care.

Patient Profile Summary

2|Page

Greene John Physician: Peterson Isolation Precautions: Allergies: None NKDA Service: Med-Surg

Code Status Information Code Status X Full Treatment Team Provider Dr. Pol Dr. Hospitalization Problems

Limited

Problem List Pain Management Declines ambulation Refuses to use incentive spirometer

3|Page

Age 64

Gender M

DOB 02/09/1954

Medical Record # 1234567890

Height: 69” 175.26cm Weight: 223lb 102.05 kg BMI: 33.2 Obese

None Role Admitting Provider Consulting Provider

From Admit

To Discharge

Greene John Physician: Peterson Isolation Precautions: Allergies: None NKDA Service: Med-Surg

Date/Time 01/22/19 1500 01/22/19 1500 01/22/19 1735 01/22/19 1735 01/22/19 1735 01/22/19 1735

Description D5LR + 20 mEq KCL Morphine PCA per protocol Enoxaparin sodium Hydrocodone / APAP Acetaminophen Ibuprofen

Age 64

Gender M

DOB 02/09/1954

Medical Record # 1234567890

Height: 69” 175.26cm Weight: 223lb 102.05 kg BMI: 33.2 Obese

Active Orders For Greene, John Medications Dose Route Rate

Freq

1000 mL

IV

125 ml/hr

Every 8 hours

1 mg / mL (30mL vial) 40 mg

IV

Q 15 min

PRN

SC

Daily

7.5 / 325 mg

PO

1000 mg

PO

800 mg

PO

Q 4 hrs PRN Moderate Pain Q 6 hrs PRN Mild Pain Q 8 hrs PRN Mild Pain

Start 01/22/19 1500 01/22/19 1500 01/22/19 0900 01/22/19 1500 01/22/19 1500 01/22/18 1500

Stop 01/23/19 1500

01/29/19 1500

Nursing Orders 01/22/19 1735

Vital signs every 4 hours x 24 hours, then every 8 hours until discharge TED hose and SCD’s in place until ambulating Discontinue Foley in AM Out of bed in before midnight Discontinue PCA 24 hours postop

01/22/19 1735

Advance diet when ambulating

01/22/19 1735

CBC in AM

01/22/19 1735 01/22/19 1735

Incentive spirometry 10 breaths every hour while awake

Diet Orders

Lab Orders Respiratory Orders O2 2L/min via NC

New Orders for Greene, John To Be Acknowledged Date/Time 01/23/19 0435

Description Bedrest Temp q 2 hours until afebrile x 24 hours. NPO Add Blood Cultures x 2 to AM labs Culture incision UA, C&S Ampicillin 2 gms IVPB every 4 hours Gentamycin 120 mg IVPB loading dose then Gentamycin 80 mg every 8 hours Peak and trough around 3rd dose Acknowledged: 01/23/2019 by CCrider, RNC @ 0500

       

Acknowledged:

4|Page

Ordering Provider Dr. Pol

Greene John Physician: Peterson Isolation Precautions: Allergies: None NKDA Service: Med-Surg

Age 64

Gender M

DOB 02/09/1954

Medical Record # 1234567890

Height: 69” 175.26cm Weight: 223lb 102.05 kg BMI: 33.2 Obese

Handwritten MAR

Initials

5|Page

Scheduled Medications Medication / Dosage / Frequency / Route

01/22 @ 0700 to 01/23 @ 0659

Non-Recurring Medications Medication / Dosage / Frequency / Route

01/22 @ 0700 to 01/23 @ 0659

Signature

07:00 – 18:59

07:00 – 18:59

Initials

19:00 – 06:59

19:00 – 06:59

Signature

Greene John Physician: Peterson Isolation Precautions: Allergies: None NKDA Service: Med-Surg

Age 64

Gender M

DOB 02/09/1954

Medical Record # 1234567890

Height: 69” 175.26cm Weight: 223lb 102.05 kg BMI: 33.2 Obese

Electronic MAR Scheduled Medications Medication / Dosage / Frequency / Route LR 1000 mL IV 125 mL/hr Morphine PCA 1mg/mL IV 4 mg bolus; 1 mg Q 15 min; 4 hr limit 30 mg Gentamycin 120 mg IVPB x 1 dose Now

Non-Recurring Medications Medication / Dosage / Frequency / Route Zofran 4mg IVP q 4 hours prn nausea and/or vomiting

Initials Signature JW JWelborn, RN (electronic signature) LW LWebster, RN (electronic signature)

Initials CC

01/21 @ 0700 to 01/22 @ 0659 07:00 – 18:59

1730 JW

0600 CC

01/21 @ 0700 to 01/22 @ 0659 07:00 – 18:59

19:00 – 06:59

1530 JW

Signature CCrider, RNC (electronic signature)

Patient Controlled Analgesia Orders 6|Page

19:00 – 06:59

2200 CC 0600 CC 0130 CC

Greene John Physician: Peterson Isolation Precautions: Allergies: None NKDA Service: Med-Surg

Age 64

Gender M

DOB 02/09/1954

Medical Record # 1234567890

Height: 69” 175.26cm Weight: 223lb 102.05 kg BMI: 33.2 Obese

01/21/19 @ 1500 1. 2.

Discontinue all previous orders for analgesia. Drug: Morphine 1 mg/mL Morphine 5 Mg/mL Hydromorphone 0.2 Mg/mL

3. 4. 5. 6. 7. 8. 9. 10.

11.

Meperidine 10 Mg/mL

Loading dose: 4mg. PCA Self-administered dose: 1mg. Lockout interval: 15 minutes Continuous Machine Administered Dose: 1mg/hr 4 hour limit 30 mg Pain management: Override: Morphine 4 mg q 2 hours as needed for breakthrough pain Assess vital signs, pain and LOC scores every 30 min. X 2, then every 2 hours x 2 after the first dose and after each change in settings, then every 4 hours prn. Treatment of adverse effects: A. Hypotension: for systolic blood pressure 90 less than mm hg, give 500 ml. Lactated ringers solution. B. Nausea: Zofran 4 mg IVP q 4hrs prn C. Respiratory depression: 1. Turn off pump 2. Attempt to arouse patient. Place pulse oximeter. 3. For respiratory rate less than or equal to 8 per minute: a) Naloxone 0.1 mg IV stat and repeat every 1-2 minutes until respiratory rate greater than 8. b) Immediately notify MD. If PCA medication incompatible with IVPB medication, place saline lock for IVPB administration.

Provider: Dr G. Passer Date: 01/22/2019 @ 1435

7|Page

RN: JWelborn, RNC, MSN Date: 01/22/2019 @ 1445

Pain Management Flow Sheet for Analgesic Infusions

PCA

PCEA

Epidural

Drug Concentration__Morphine 30mg (1mg/mL)_______________________________ Allergies__NKDA _________________________________________ Insertion Site: Set-up Verification_JW / CL______________ by 2 Licensed RNs Yes No JWelborn, RN Signature CLivengood, RN Signature Date

Time

Amount Infused mL

Amount Remaining mL

Amount Wasted mL

Dose

Cont Rate

Loading Dose / Bolus

4 Hr Limit

01/22

1500 1700 1900 2100 2215 2215 2300 0100 0300 0400 0500 0700

0 9 17 25 30 0 3 11 15 20 21 22

30 21 13 5 0 30 27 19 15 10 9 8

0 0 0 0 0 0 0 0 0 0 0 0

1 mg 1 mg 1 mg 1 mg 1 mg 1 mg 1 mg 1 mg 1 mg 1 mg 1 mg 1 mg

1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0

4 4 0 0 0 0 0 0 4 5 0 0

30 30 30 30 30 30 30 30 30 30 30 30

01/23

Epidural Catheter Removal

Patient Assessment

Pain Rate 10 8 2 2 2 2 2 2 6 7 0 0

Resp Rate 22 20 16 16 16 14 14 16 18 20 16 16

Epidural

LOS

S/E

na 3 2 2 2 S S S 1 1 S S

na N M M M M M M N M M M

B P

Comments

Pulse

Vial #1 up; verified x2 RNs Bolus: breakthough pain Shift change verification x2 Vial #1 complete Vial #2 up, verified x2 RNs

Bolus: breakthough pain Bolus: breakthough pain Shift change verification x2

Init JW JW LW LW CC CC CC CC CC CC CC

Infusion System Assessment

“Epidural catheter site clean, dry; no redness, warmth, edema or tenderness noted; Catheter removed with blue tip intact.” ___ = Agree Time_____________ Signature _____________________

“Infusion system securely taped, tubing patent, reservoir has volume, and parameters are set as ordered. Patient button within reach, connected to pump, and functioning properly.” Initials JW/CL Initials JW/LW Initials LW/CC Initials CC and _____ New Tubing ______ Time ____________ Initials _____ _____

Patient Assessment Codes LOS = Level of Sedation S = Sleep 1 = Alert, Easy to arouse 2 = Occasionally drowsy; Easy to arouse 3 = Frequently drowsy 4 = Somnolent; Difficult to arouse

Pain Management Flow Shet for Analgesic Infusions

S/E = Side Effects M = Medicated N = Nausea V = Vomiting P = Pruritus UR = Urinary Retention SL = Sensory Loss MW = Muscle Weakness

PCA

PCEA

ElectronicSignature JWelborn, RN

Init JW

CLivengood, RN LWebster, RN CCrider, RNC

CL LW CC

Epidural

Drug Concentration__Morphine 30mg (1mg/mL)_______________________________ Allergies__NKDA _________________________________________ Insertion Site: Set-up Verification_JW / CL______________ by 2 Licensed RNs Yes No JWelborn, RN Signature CLivengood, RN Signature

8|Page

Date

Time

Amount Infused mL

Amount Remaining mL

Amount Wasted mL

Dose

Cont Rate

Loading Dose / Bolus

4 Hr Limit

Epidural Catheter Removal

Patient Assessment

Pain Rate

Resp Rate

LOS

Epidural

S/E

B P

Init

Infusion System Assessment

“Epidural catheter site clean, dry; no redness, warmth, edema or tenderness noted; Catheter removed with blue tip intact.” ___ = Agree Time_____________ Signature _____________________

“Infusion system securely taped, tubing patent, reservoir has volume, and parameters are set as ordered. Patient button within reach, connected to pump, and functioning properly.” Initials JW/CL Initials JW/LW Initials LW/CC Initials CC and _____ New Tubing ______ Time ____________ Initials _____ _____

Patient Assessment Codes LOS = Level of Sedation S = Sleep 1 = Alert, Easy to arouse 2 = Occasionally drowsy; Easy to arouse 3 = Frequently drowsy 4 = Somnolent; Difficult to arouse

9|Page

Comments

Pulse

Electronic Signature S/E = Side Effects M = Medicated N = Nausea V = Vomiting P = Pruritus UR = Urinary Retention SL = Sensory Loss MW = Muscle Weakness

Init

0600 – 1800 Vital Signs / Intake & Output Summary Date:

01/22 – 01/23

Time

0700

0800

0900

1000

1100

1200

Vital signs BP

S D

Pulse Resp Temp SaO2 Pain

105 55 116 22 103.2 98 5/10

Intake Po IV IVPB Blood TPN Tube Other Total In

Output Urine Emesis Drains Other Stool Ostomy Blood Total out

10 | P a g e

1300

1400

1500

1600

1700

1800

1800 - 0600 Vital Signs / Intake & Output Summary 01/21 – 01/22

Date: Time

1900

2000

2100

2200

2300

0000

0100

0200

0300

0400

0500

0600

Vital signs BP

S D

137 82 74 16 97.8 94 6/19

Pulse Resp Temp SaO2 Pain Po IV IVPB Blood TPN Tube Other Total In

Ice 125

Ice 125

125 72 72 18 98.3 95 3/19

Ice 125

Ice 125

Ice

Intake Ice

125

125

114 67 96 22 103.3 93 5/19

Ice

Ice

Ice

Ice

NPO

NP O

125

125

125

125

125

125 Gent

1500

Output Urine Emesis Drains Other Stool Ostomy Blood TotalOut

11 | P a g e

300

550

650

400

1900

DIABETIC SLIDING SCALE RECORD DATE/TIME

BLOOD SUGAR

SLIDING COVERAGE NEEDED Y

INSULIN

HOUR

TYPE

DOSE

INJECTION SITE

CARB GRAMS EATEN

RN INITIALS X2 ADMIN / CONFIRM

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

SLIDING SCALE Insulin Sliding Scale Blood Glucose (Except Hs) 110-150 151-200 201-250 251-300 301-350 351-400 > 400

Regular

Insulin Aspart (Novolog) Mild Moderate (Thin, Npo, Or Elderly) (Avg. Weight &Eating) 1 Unit 3 Units 2 Units 5 Units 4 Units 7 Units 6 Units 9 Units 8 Units 11 Units 10 Units 13 Units Call MD Call MD

Night Insulin Sliding Scale Regular Night (Hs) Blood Glucose 110-150 151-200 201-250 251-300 301-350 351-400 > 400

12 | P a g e

Aggressive (On Steroids Or Infected) 4 Units 6 Units 10 Units 12 Units 15 Units 18 Units Call MD

Insulin Aspart (Novolog) Night (Hs) (Do Not Use If On Tpn/Tf) None 2 Units 3 Units 4 Units 5 Units 6 Units Call MD

Hematology

Complete Blood Count White Blood Cells

Date 01/21/19 Time 0900

Date 01/23/19 Time 0500

12.5

19.7

Date

Date

Time

Time

Range

> 2 yrs old 5000 – 10000

Red Blood Cells

4.40

3.98

Hemoglobin

12.5

8.2

Hematocrit

36.3

28.4

Platelet Count

233

135

79.5 13.2 6.7 0.3 0.3

93 1 2 0.3 0.3

Differential Count Neutrophils Lymphocytes Monocytes Eosinophils Basophils Cardiac Profile Ck Ck MB Cardiac Specific Troponins: B-Natriuretic Peptide Clotting Studies Prothrombin Time Internat’l Normalized Ratio Partial Thromblplastin Time Activated Clotting Time Lipid Profile Cholesterol High Density Lipoprotein Low Density Lipoprotein Triglycerides

13 | P a g e

M: 4.7 - 6.1 F: 4.2 - 5.4 M: 14 – 18 F: 12 – 16 M: 42 – 52 F: 37 – 47 150 – 400 (thousand) 55 – 70 20 – 40 2–8 1–4 0.5 - 1.0 M: 55 – 170 F: 30 – 135 -0< 0.2 < 0.03 < 100 11 – 12.5 0.8 – 1.1 60 – 70 70 – 120 < 200 M: > 45 F: > 55 < 130 M: 40 – 60 F: 35 – 135

Chemistry Date 01/21/19 Time 0900 Complete Metabolic Profile *Basic Metabolic Profile *Sodium *Potassium *Chloride *Co2 *Glucose *Calcium Albumin Total Protein *Blood Urea Nitrogen *Creatinine

138 3.1 101 26 104 8.5 3.6 6.8 13 1.3

Alkaline Phosphatase Alanine Aminotransferase Aspartate Aminotransferase Bilirubin GFR BC ratio

73 41 20 1.0 57 10

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