MED-SURG SCORE: 81 TIME ELAPSED: 1:42 PAUSE Lithia Monson Room 302 Lithia Monson 93 years old, came to us yesterday with a fall at the nursing home with a suspected subdural hematoma. She seems stable, difficult to determine her level of confusion as she has dementia. She has a bump on her head. Ms. Monson is cooperative, direct-able, and we do not see any changes. Vital signs are stable -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%, She is oriented with some direction to time and place. Her speech is clear. She did not recognize her son today when he came to see her, but that is not new for her. Q1 hour nuero assessments and we are watching her closely. We have asked the family to stay with her 100% of the time so she does not fall. Strict I&O, Hep-Lock in place left AC although no IV therapy going. Ms. Monson is a patient of Dr. Altace You responded correctly to 5 out of 6 evaluations: Category Your response Explanation Educational Needs Increased acuity Status assessment reports head injury, Dementia, confusion, recent fall, poor intake, and assistance with bath. Fall Risk Increased acuity Status assessment reports head injury, Dementia, fall one day ago, confusion to time/ place, family sitter, and assistance with bath. Health Change Increased acuity Status assessment reports head injury- r/o subdural hematoma, recent fall, Confusion, strict I&O, intake 50%. Pain Level X Increased acuity No indication of pain Psychological Needs Increased acuity Status assessment reports history of dementia, confusion-time/place, poor historian, didn't recognize son. Increased acuity Sensorium Status assessment reports head injury, Dementia, fall x 1 day, confusion-time/place, didn't recognize son, neuro assessment q1 hr. CONTINUE... Lithia Monson Lithia Monson 93 years old, came to us yesterday with a fall at the nursing home with a suspected subdural hematoma. She seems stable, difficult to determine her level of confusion as she has dementia. She has a bump on her head. Ms. Monson is cooperative, direct-able, and we do not see any changes. Vital signs are stable-Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. She is oriented with some direction to time and place. Her speech is clear. She did not recognize her son today when he came to see her, but that is not new for her. Q1 hour nuero assessments and we are watching her closely. We have asked the family to stay with her 100% of the time so she does not fall. Strict I&O, Hep-Lock in place left AC although no IV therapy going. Ms. Monson is a patient of Dr. Altace You correctly diagnosed 12 out of 12 options: Physiological Description Your Response Explanation Alteration in nutrition True Status assessment reports patient with 50% diet consumption Ineffective cardiac/perfusion False Status assessment reports no indication cardio issues Nausea False Status assessment reports no indication of 'Nausea' Potential for bleeding True Status assessment reports patient experienced head injury Potential for shock False Status assessment reports no indication of symptoms relating to shock. Self-care deficiency True Status assessment reports patient experiencing confusion and needs assistance with ADL's. Safety Description Acute Confusion Peripheral Neurovascular Dysfunction False Potential for falls Sleep deficit Your Response Explanation True Status assessment reports patient disoriented to time and place. Status assessment reports no indication of 'Peripheral Neurovascular Dysfunction'. True Status assessment reports patient history of falls. False Status assessment reports no indication of inability to sleep. MED-SURG SCORE: 86 TIME ELAPSED: 6:00 PAUSE Lithia Monson Scenario 1 You arrive in room to find Ms. Monson talking to herself. Upon assessment, you determined that she is confused to person, time, and place but is easily directable. You correctly ordered 5 out of 5 actions: Is this order correct Your order Correct order Step 1 1 Perform neuro assess Reorient Patient to person, place, & time Assess for fall risk Offer nutrition/toilet Discuss effectiveness of sitter Explanation Address patient issue by specific assessment of neurological status. 2 2 After neuro assessment, patient now can be reoriented and educated. 3 3 Patient safety is a concern before and after allowing opportunity to eat or go to bathroom. 4 4 Least of priorities. Other steps must be performed prior to interventions. 5 5 To ensure patient compliance, and promote safety CONTINUE