Student Simulation Preparation: GI/ Sepsis
Student Learning Objectives:
1. Focused post-op assessment
2. Assess and care for colostomy
3. Assess for signs and symptoms of sepsis
4. Educate patient on colostomy care.
Preparation for scenario:
Read Pearson Module 10.C – Inflammation
Nursing Skills: 4, 4.18 and 4.19
GI/ Sepsis Student Worksheet
I. Data Collection
History of Present Problem:
Justine Walsh, is a 45 year old female diagnosed with Crohn’s Disease. Patient admitted through the Emergency Department with abdominal pain and hematochezia for 2 weeks. S/p hemicolectomy with a colostomy. Transferred to the medical/surgical unit for continued care and education. PMH of Crohn’s Disease and anxiety.
Personal/Social History:
Married with two young children. No history of smoking, alcohol or drug use.
RELEVANT Data from Present Problem:
Clinical Significance:
RELEVANT Data from Social History:
Clinical Significance:
PMH:
Home Meds:
Pharm. Classification:
Expected Outcome:
Pantoprazole (Protonix)
Lorazepam (Ativan)
1.
2.
1.
2.
Current VS:
WILDA Pain Assessment (5th VS):
T: (oral) 99oF
Words:
sore
P: (regular) 88
Intensity:
4/10
R: (regular) 20
Location:
At incision site
BP:142/88
Duration:
surgery
O2 sat: 99% on RA
Aggravate:
Alleviate:
Nothing
medication
What VS data is RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT VS Data:
Clinical Significance:
Current Assessment:
GENERAL APPEARANCE:
Resting in bed, appears in no acute distress
RESP:
Nonlabored respiratory effort. Diminished breathe sounds bilateral LL.
CARDIAC:
Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks
NEURO:
Alert & oriented to person, place, time, and situation (x4)
GI:
Abdomen soft, no bowel sounds audible per auscultation in all four quadrants. Abdomen tender to touch. Colostomy stoma beefy red.. Abdominal incision DSD intact, no drainage noted.
GU:
Foley Catheter draining urine clear/yellow
SKIN:
Abdominal incision, 14 staples, DSD C/D/I. Colostomy stoma protruding and beefy red.
What assessment data is RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Assessment Data:
Clinical Significance:
Nursing Interventions:
Rationale:
Expected Outcome:
Medical Management: Rationale for Treatment & Expected Outcomes
Care Provider Orders:
Rationale:
Expected Outcome:
1. OOB to chair x30 min. BID
2. NPO
3. NGT to low continuous suction
4. Accu check q6hr
5. Foley catheter
6. Strict I&O
7. DSD dressing change daily and prn to keep dry
8. Assess stoma qshift
9. PICC line care
PRIORITY Setting: Which Orders Do You Implement First and Why?
Order of Priority:
Rationale:
Medication Dosage Calculation:
Medication/Dose:
Mechanism of Action:
Volume/time frame to Safely Administer:
Nursing Assessment/Considerations:
PPN standard at 125ml/hr
Morphine 2mg IVP prn q4 hours for moderate pain
Cefazolin (Ancef) 2gm IVPB q12hours
Lab Results:
What lab results are RELEVANT that must be recognized as clinically significant to the nurse?
Complete Blood Count (CBC:)
Current:
High/Low/WNL?
WBC (4.5–11.0 mm 3)
11.8
Hgb (12–16 g/dL)
12
Platelets (150-450 x103/µl)
245
Neutrophil % (42–72)
43
Band forms (3–5%)
4
What lab results are RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Lab(s):
Clinical Significance:
Basic Metabolic Panel (BMP:)
Current:
High/Low/WNL?
Sodium (135–145 mEq/L)
136
Potassium (3.5–5.0 mEq/L)
3.6
Chloride (95–105 mEq/L)
96
Glucose (70–110 mg/dL)
106
Calcium (8.4–10.2 mg/dL)
8.5
BUN (7–25 mg/dl)
9
Creatinine (0.6–1.2 mg/dL)
0.8
RELEVANT Lab(s):
Clinical Significance:
Situation:
Background:
Assessment:
Recommendation:
