V Sim - Linda Waterfall

vSim ISBAR ACTIVITY STUDENT WORKSHEET INTRODUCTION Your name, positon (RN), unit you are working on SITUATION Linda Waterfall, a 48-year-old Native American female, diagnosed with an aggressive form of breast cancer and is scheduled for a left mastectomy this morning Patent’s name, age, specific reason for visit BACKGROUND Patent’s primary diagnosis, date of admission, current orders for patent ASSESSMENT Current pertnent assessment data using head to toe approach, pertnent diagnostcs, vital signs RECOMMENDATION Any orders or recommendatons you may have for this patent The patient was diagnosed with an aggressive form of breast cancer after results were collected from a biopsy on the left breast last week upon admission on 1/22/2022. Current orders: Lorazepam 2mg once PO preoperatively at 06:00 Vital signs once every 8 hours IV dextrose 5% lactated Ringer’s at 80 mL/h NPO except medications The patient is alert and oriented x3 with an appropriate appearance. The patient is visibly distressed due to surgery today and presents with elevated vital signs consistent with anxiety related to her scheduled mastectomy today. When asked when she felt her best over the past year the patient stated, “You are trying to kill me by making me go through this surgery without it. All of you are out to get me. You want me to die!” Current vital signs: BP= 140/75 mmHg HR: 100/min RR: 18 breaths/min SpO2: 100% Temp: 99 F Recommendations include deep breathing exercises and relaxation techniques to aid and reduce anxiety towards the surgery. Educate the patient on the rights of autonomy on her decision in having the surgery, postpone, or cancel it. Educate the patient on the risks and benefits of surgery. Discuss and collaborate the healthcare plan with the provider and the patient and how to move forward with care. PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Lorazepam CLASSIFICATION: benzodiazepine, antianxiety PROTOTYPE: lorazepam SAFE DOSE OR DOSE RANGE, SAFE ROUTE 2-6 mg/day PO in divided doses with largest before bedtime PURPOSE FOR TAKING THIS MEDICATION Preoperative sedative to ease anxiety associated with surgery PATIENT EDUCATION WHILE TAKING THIS MEDICATION Educate the patient on the adverse reaction to this class of drugs. It includes CNS effects and respiratory depression at high doses. The patient is prescribed 2 mg tablet PO once preoperatively. Educate on paradoxical reactions such as increased anxiety, excitation, agitation, sleep disturbances, and mood changes that may occur. Educate that pre-existing depression may appear or worsen when using this drug. In addition to increased abuse potential, it may cause physical and psychological dependence. This drug should not be used in patients with compromised respiratory function. Educate on other CNS depressants such as alcohol, barbiturates, antipsychotics, antidepressants, antihistamines using this drug will only increase CNS-depressant effects. PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: CLASSIFICATION: PROTOTYPE: SAFE DOSE OR DOSE RANGE, SAFE ROUTE PURPOSE FOR TAKING THIS MEDICATION PATIENT EDUCATION WHILE TAKING THIS MEDICATION PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: CLASSIFICATION: PROTOTYPE: SAFE DOSE OR DOSE RANGE, SAFE ROUTE PURPOSE FOR TAKING THIS MEDICATION PATIENT EDUCATION WHILE TAKING THIS MEDICATION PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: CLASSIFICATION: PROTOTYPE: SAFE DOSE OR DOSE RANGE, SAFE ROUTE PURPOSE FOR TAKING THIS MEDICATION PATIENT EDUCATION WHILE TAKING THIS MEDICATION Clinical Worksheet Assigned vSim: Linda Waterfall Initials: : LW Diagnosis: Breast cancer HCP: N/A Isolation: none Age: 48 y/o M/F: Female Code Status: Length of Stay: 10 days Fall Risk: Standard IV Type: Peripheral IV Critical Labs: Consults: N/A Allergies: none Transfer: from Emergency Department Other Services: none Location: Right forearm Fluid/Rate: Dextrose 5% lactated Ringer’s 80 mL/h Consults Needed: Dr. Samuels Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: The patient is anticipating a mastectomy of her left breast today due to a diagnosis of an aggressive form of breast cancer after a biopsy was done a week ago. The patient appears to exhibits outward signs of anxiety and needs support. Health History/Comorbities (that relate to this hospitalization): none Shift Goals/ Patient Education Needs: 1. Provide support for patient and family 2. Educate patient on autonomy in health care choices 3. Collaborate the health care plan with surgeon and patient 4. Discuss patient’s feelings/emotions towards surgery 5. Gain a better understanding of patient’s culture and spirituality Path to Discharge: Patient will be discharged once the health care options are discussed with the surgeon and the patient is seen and has given confirmation to go through with the surgery. If the patient decides to go through with surgery, then the healthcare team will proceed with surgery and decide on the discharge options post-op. The patient will appear relaxed and, at ease with the ability to rest/sleep. The patient will be able to acknowledge feelings and discover ways to deal with them. Path to Death or Injury: If the patient demonstrates and exhibits signs of harming herself or others due to immense stress, anxiousness, and fears towards surgery. Alerts: What are you on alert for with this patent? (Signs & Symptoms) 1. Decreased self-assurance and worry 2. Difficulty breathing due to anxiety and stress 3. Expressed concern and fear regarding changes What Assessments will focus on for this patent? (How will I identfy the above signs &Symptoms?) 1. Management of Care: What needs to be done for this Patient Today? 1. Educate the patient on autonomy of choices regarding health and surgery 2. Provide support for patient and family 3. Discuss the patient’s feelings towards surgery 4. Collaborate a treatment plan with patient and physician 5. Deescalate the patient’s anxiety with deep breathing and the use of other soothing means. Observe patient’s appearance for external signs of anxiety 2. Monitor vital signs for elevations indicating anxiety and stress 3. Perform mental status exam List Complications may occur related to dx, procedure, comorbidites: 1. Patient may be too agitated to answer any questions 2. Patient may not be able to think clearly or make rational decisions due to situational anxiety 3. Patient may refuse life-saving surgical treatment What nursing or medical interventions may prevent the above Alert or complicatons? 1. If the patient decides to have surgery. Discuss the use of the prescribed benzodiazepine to reduce the patient’s anxiety in relation to surgery 2. Validate fears and provide factual information to ease tension 3. Identify fears and anxiety that may contribute to postponing the surgery 4. If fears and anxiety are not reduced or resolved, discuss postponing or cancelling the surgery with the physician, patient, and family Priorities for Managing the Patient’s Care Today 1. Discuss treatment options for patient to ease anxiety 2. Observe the patient appearance for signs of anxiety 3. Auscultating lung and heart sounds 4. Assess vitals for signs of anxiety What aspects of the patient care can be Delegated and who can do it? The nurse can assist and complete vital signs, administer medicatons, educate patent anxiety triggers and management Description/Pathophysiology Situatonal anxiety is a type of anxiety that occurs as a response to a stressful situaton. This form of anxiety is usually a normal response to a change or event that instlls fear or uncertainty in a patent. Etiology/causes/risk factors Anxiety is brought on by fear of the unknown, different stressors, or sudden change. In the central nervous system, neurotransmitters such as serotonin, dopamine, norepinephrine, and gammaaminobutyric acid are linked to anxiety and mood disorders. These neurotransmitters are triggered by the amygdala in a fight or flight response causing the sudden fear and anxiety that an individual may feel in stressful situatons. Clinical manifestations/Nursing assessment Signs and symptoms may include experiencing a sense of impending danger, pain or doom; increased heart rate; hyperventlaton; sweatng; feeling weak or tred; difficulty concentratng or decisionmaking. Assess for presence of cultural influence on anxiety state; Assess level of anxiety; validate observatons by asking patent how they are feeling. Diagnostic tests - Vital signs - Head-to-toe assessment - Mental status exam HEALTH PROBLEM: Situational Anxiety Nursing interventions/considerations - Evaluate the patent’s feelings about diagnosis and determine level of anxiety and expectatons - Encourage deep breathing exercises to reduce anxiety - Comfort patent to promote relaxaton and relieve anxiety - Assess the patent’s and family’s ability to cope and reduce levels of stress - Converse using a simple language and brief statements Patient Teaching - Educate the patent on process of the surgery. The outcomes should be measured to provide relaxaton and peace of mind for the patent and family. Remediation/Other None Treatment/Procedures - Therapeutc communicaton - Antanxiety medicaton - Psychotherapy If anxiety and fear is unable to relieved educate on how to reduce levels of stress and anxiety using healthy methods. -Educate patent to recognize symptoms of anxiety during stressful situatons and when to practce healthy strategies to manage anxiety. Nursing Diagnoses Anxiety: may be related to situatonal and maturatonal crises Possibly evidenced by Feelings of discomfort, apprehension or helplessness Fear: may be related to Physiological symptoms, mental/cognitve behaviors indicatve of panic Possibly evidenced by Acknowledge and discuss fears. Priority diagnosis/interventions Fear/anxiety is the primary diagnosis and the nurse must monitor for changes in levels of fear and anxiety; encourage deep breathing; discuss the patent feelings toward diagnosis and surgery; support patent and family; discuss care plan with patent and surgeon