Stan Checketts VSIM documentation and guided reflection PDF

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Stan Checketts guided reflection and documentation questions for vsim....

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Surgical Case 2: Stan Checketts Documentation Assignments 1. Document your focused assessment of Stan Checketts’ abdomen. - Patient was A&O x 4, auscultation of the lungs revealed normal breath sounds bilaterally. Auscultation of the heart revealed normal S1 and S2 w/o any murmurs. Auscultation of abdomen revealed hyperactive bowel sounds. Pt’s vital signs were as follows: Respirations were 28 breaths per minute w/ normal chest movement bilaterally, heart rate was 130, sinus tachycardia, SPO2 was 90% at the beginning of assessment and blood pressure was 108/76 mmHg. Abdomen was distended, and patient complained of 4/10 aching abdominal pain and nausea. 2. Document immediate priority actions related to the treatment of hypovolemic shock. - It is very critical to treat the sudden drop in blood pressure that is related to hypovolemic shock. To do this I needed to replace the fluid loss by isotonic fluid resuscitation. Therefore, administration of NS 500 ml IV bolus over 30 minutes after assessment. The 2L of oxygen. Was given via nasal canula for the treatment of the low SPO2, metabolic alkalosis, and compensating rapid respirations. 3. Document the changes in Stan Checketts’ vital signs throughout the scenario. -The oxygen saturation become 93%, Pulse 120, BP 106/76, pain level decrease from 4 to 2 4. Identify and document key nursing diagnoses for Stan Checketts. - Risk for decreased cardiac output as evidenced by fluid loss due to vomiting - Risk for imbalanced fluid volume - Risk for electrolyte imbalance - Risk for shock 5. Referring to your feedback log, document the nursing care you provided. - While caring for Stan Checketts and referring back to my feedback log, my main priority was following the physician’s orders and making sure his vitals stayed within normal range limits. I also made sure I used interventions within a nurse’s limitations to improve any vital signs that were not within the normal limits, such as the sPO2:

Surgical Case 2: Stan Checketts Guided Reflection Questions 1. How did the scenario make you feel? © Wolters Kluwer Health | Lippincott Williams & Wilkins

- The scenario made me feel great! I actually really enjoyed it and it made me apply my knowledge. I’ve always just read the books or followed PowerPoints but it felt different to finally put my critical thinking to use. 2. When reflecting on the care of Stan Checketts, what are signs and symptoms you can assess in the next patient you care for who might be at risk for dehydration? - VITAL SIGNS! If a patient’s blood pressure is fairly low but their HR is high, I would definitely look out for dehydration and also their skin turgor results and capillary refill. 3. Discuss signs and symptoms of hypovolemic shock. - Dizziness is a sign of hypovolemic shock that Stan was actually experiencing. He told the nurse Dan multiple times that he felt dizzy. A few other S/S of hypovolemic shock are rapid breathing, cool, clammy skin and decreased urine output. 4. Discuss assessment and expected findings in a small bowel obstruction. -The patient with a small bowel obstruction will usually present with abdominal pain, abdominal distension, vomiting, and inability to pass flatus 5. What key questions does the nurse ask in an acute abdominal pain assessment? - What causes the pain? - What does it feel like, can you describe the pain? - Where is the pain located, does the pain radiate anywhere? - How bad is the pain on a scale of 1-10 - When did the pain start, what were you doing when the pain started? 6. In evaluating Stan Checketts’ laboratory values, what if any abnormalities did you find?

he abnormal labs were Sodium, urea nitrogen, creatinine, Hemoglobin, Hematocrit and White Blood Count. - The abnormal labs were Sodium, urea, nitrogen, creatinine, Hgb, Hematocrit and WBC 7. Stan Checketts had a nasogastric (NG) tube inserted for gastric decompression. What are the preferred methods for confirming placement of the NG tube? - The preferred method to confirmed placement would be X-Ray 8. What key elements would you include in the handoff report for this patient? Consider the SBAR (situation, background, assessment, recommendation) format. - A 52-year-old white male, with severe abdominal pain, nausea and vomiting for the past few days. His abdomen is distended and tender with poor skin turgor and dry mucous membranes. He has not urinated since last night.

© Wolters Kluwer Health | Lippincott Williams & Wilkins

9. What would you do differently if you were to repeat this scenario? How would your patient care change? - After completing this vsim a few times, I started to get the hang of it, the only mistake that I made was reassessing the patients nausea after giving medication.

© Wolters Kluwer Health | Lippincott Williams & Wilkins...