Surgical Case 2: Stan Checketts Documentation Assignments 1. Document your focused assessment of Stan Checketts’ abdomen. a. The abdomen was bloated and tender to touch. His skin was cold and there was decreased skin turgor. There were hyperactive bowel sounds. 2. Document immediate priority actions related to the treatment of hypovolemic shock. a. I started an IV of isotonic fluid at a bolus of 500 ml / 30 mins. 3. Document the changes in Stan Checketts’ vital signs throughout the scenario. a. My first assessment of vital signs showed: HR 131, BP 108.77, RR 29, SpO2 90% and temperature 99 F. My last assessment of vital signs showed: HR 116, BP 106/76, RR 28, SpO2 93% and temperature 99 F 4. Identify and document key nursing diagnoses for Stan Checketts. a. Deficient fluid volume r/t inadequate fluid volume intake 5. Referring to your feedback log, document the nursing care you provided. a. After introducing myself and washing my hands, I got vitals on Mr. Checketts and then performed an abdominal assessment by auscultating the abdomen first and then palpating it. I then started an IV and gave fluids after assessing the patency of the IV. I placed an NG and checked placement by X-ray. I got a venous blood sample for a CBC and metabolic panel. I got an abdominal X-ray for diagnostic purposes. I then gave buprenorphine IV for pain and ondansetron IV for nausea. I placed a NC on Mr. Checkettes to increase his SpO2 from 90-93% and I put it on 2L. I re-examined his abdomen and re-assessed his pain. I updated the physical and educated the patient appropriately. Guided Reflection Questions 1. How did the scenario make you feel? a. I felt great during this scenario! I felt like a real nurse and knowledgable. I was able to complete this scenario in one attempt 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? a. Skin turgor, headache, nausea, 3. Discuss signs and symptoms of hypovolemic shock. a. Hypotension, tachycardia, tachypnea, decrease in LOC, oliguria, cool clammy skin, fatigue, weakness 4. Discuss assessment and expected findings in a small bowel obstruction. a. Abdominal pain b. Decrease in appetite 5. 6. 7. 8.  9. c. Constipation d. Vomiting e. Inability to have a BM or flatulence f. Distended abdomen What key questions does the nurse ask in an acute abdominal pain assessment? a. Have you had any changes in your appetite? b. Have you had any unintentional weight loss or gain? c. Have you had any trouble swallowing? d. Are you nauseous or having any episodes of vomiting? e. Do you have any abdominal pain? f. Any changes in your bowel patterns? g. What medications are you taking? h. Do you drink alcohol or smoke? In evaluating Stan Checketts’ laboratory values, what if any abnormalities did you find? a. Elevated hematocrit is suggestive of dehydration b. Elevated pH and elevated HCO3 is suggestive of metabolic alkalosis d/t vomiting Stan Checketts had a nasogastric (NG) tube inserted for gastric decompression. What are the preferred methods for confirming placement of the NG tube? a. pH aspiration: if pH is < 5 then placement is correct b. X-ray: picture shows placement What key elements would you include in the handoff report for this patient? Consider the SBAR (situation, background, assessment, recommendation) format. a. S: Stan Checketts presents to the ED with severe abdominal pain, nausea and vomiting b. B: Checckets is a 52 yo white male. He hasn’t urinated since yesterday and has had increasing stomach pains. Has been vomiting for the last few days c. A: hyperactive bowel sounds with a distended and tender abdomen. Skin is cool and clammy with decreased skin turgor. d. R: Isotonic IVF, antiemetic, analgesics, and surgery for small bowel obstruction. What would you do differently if you were to repeat this scenario? How would your patient care change? a. Nothing, this was my first time completing a scenario with a 100% on my first attempt! about:blank 2/3