Mark Robinson
is a 52-year-old advertising executive. He presented to the Emergency Department complaining of abdominal pain with a history of black stools for 5 days. He is also complaining of lightheadedness when he tries to stand, and prior to that he has been extremely fatigued to the point that he had to take a couple days off work. He thought he was coming down with the flu, so he has been taking Motrin 800mg twice a day. He is currently on Prednisone 30 milligrams a day for Behcet's disease, and Cardizem 120 mg a day for hypertension. He has admitted to taking twice his Prednisone dose as he is had a flare up with his gout. Mr. Robinson admits to drinking two to three alcoholic beverages daily. His respirations are equal and unlabored, bowel sounds are active in all four quadrants, he is pale and diaphoretic. Vital signs are BP: 109/58, P: 102, R: 18, SpO2 95, T emp 97.6 F, 36.4 C. Labs are pending; they had to be redrawn as the lab stated that the blood, they sent was hemolyzed. He has been admitted to the floor for a GI work up, and a possible blood transfusion.
You correctly diagnosed 5 out of 7 options:
Physiological
Description Your Response
Bleeding, risk for False Potential esophageal varices
Impaired comfort True Abdominal pain and lightheadedness
Safety
DescriptionYour
Response Explanation
Deficient Knowledge TrueNeed for dietary, self-medicating inappropriately, medication interactions, and potential ETOH dependence.
ETOH withdrawal, risk for TrueUnknown alcohol dependence level, but patient admits to drinking daily
Grieving FalseNo indication at this time
Infection, Risk for TrueNo indication at this time DescriptionYour
Response Explanation
Peripheral Neurovascular Dysfunction FalseNo indication at this time
You correctly ordered 1 out of 5 actions:
Your
orderCorrect
order Step 11Educate patient on immediate plan of care in need for T&C and large bore IVT o assure patient compliance 42Draw labs, to include a T&C and repeat stat hemoglobin and hematocritT o determine emergent blood needs, and due to crystalloids given in the ED. The patient’s blood may be diluted causing the hemoglobin to be inaccurate. 23Initiate large bore IV, 18 gauge minimal T o prevent RBC destruction from a small catheter 54Advise patient not to get out of bed without assistancePatient is a fall risk 35Initiate intake/output T o monitor intake/output, kidney function, and hemodynamic ststus closely while administering blood
You correctly ordered 3 out of 5 actions:
Your
orderCorrect
order Step 11Stop the patient from eating more of the
food until they can verify with the HCPT o prevent aspiration during impending procedures 22Explain to the wife that he cannot have any food brought in at this timeIn order to maintain special diet needs/NPO 53Reassess patient for any bleeding Patient needs frequent reassessment (vital signs, bruising, frequent stools, vomiting coffee ground substance) due to signs of acute upper/lower GI bleed 44Call GI provider to explain what happened, and verify diet and NPO statusHealthcare Provider will be the one performing the diagnostic/treatment procedures 35Explain to patient and wife the potential proceduresT o encourage patient and family compliance with the plan of care
You correctly ordered 2 out of 5 actions:
Your
orderCorrect
order Step 11Identify the client according to facility/agency policy prior to administration of red blood cells/ blood products (e.g., prescription for administration, correct type, correct client, cross matching complete, consent obtained)Ensures patient is receiving the correct blood. This is accomplished by matching 2 patient identifiers of unit numbers and patient transfusion ID wristband. This must be verified by 2 licensed nurses. 22Check the client for appropriate venous access for red blood cell/blood product administration (e.g., correct gauge needle, integrity of access site)18 gauge minimal to ensure the blood is flowing appropriately, and maintain RBC integrity Your
orderCorrect
order Step 53Document necessary information on the administration of red blood cells/blood productsDated and timed, 2 nurses’ signatures 34Check vital signs then slowly begin administration through Y-
tubing with normal salineWatching for immediate adverse reactions, and be prepared to stop blood transfusion 45Recheck VS q 5 min for 15 min then q 15 min for 1 hr. Necessary to catch impending reactions
You correctly ordered 1 out of 5 actions:
Your
orderCorrect
order Step 31Repeat H&H T o determine presence of bleeding, and treatment effectiveness 22Administer ordered medications ASAP Sucralfate binds to the ulcers to promote immediate healing. Proton pump inhibitors are the standard of care for active bleeding ulcers. 13Explain to the patient that a sore throat is normal after this type of procedure, but to notify you immediately if there is any blood tinged sputumPotential trauma to the esophageal varices during the endoscopy, significant bleeding could occur with grave patient consequences 54Verify with blood bank that 4 units ordered are on hand T o ensure blood is readily available if needed 45Verify soft, low sodium diet with HCP Soft diet is recommended after endoscopy, and when esophageal varices have been indentified
You correctly ordered 0 out of 5 actions:
Your
orderCorrect
order Step 21Stop the platelets Patient has signs and symptoms of a reaction; proper procedure was not followed 52Reassess vital signs and obtain UA T o determine significance of blood reaction. In a blood reaction lysed blood cells will be present in urine 13Notify HCP Emergent care may be required 34Call charge nurse/nursing supervisor Nurse leadership must be informed immediately of sentinel events 45Initiate incident report after patient has been stabilizedT o ensure nursing actions are reviewed, and nursing education can be provided
Calvin Umbyuma Room 302
Calvin Umbyuma, Mr. Umbyuma is a 42 y/o male who has been admitted for complaints of shortness of breath with pleuritic chest pain. He was diagnosed
with HIV positive antibodies over a year ago. He has recently been traveling back to his home country of Kenya to visit his sick mother. He received traditional medical treatment at his village. His temp is 100.9 F, 38.3 C, R 22,
P92, BP 152/89. Inflammatory markers – Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) are elevated at 78.9 mm/h and 67.2 mg/L. He has been placed in a room at the end of the hall.
You responded correctly to 4 out of 6 evaluations:
Category Your response Explanation
Educational Needs Increased acuity Patient needs HIV spread prevention education, and current treatments available
Fall risk Normal acuity No indication at this time
Health change Increased acuity Presence of shortness of breath, and pleuritic chest pain
Pain level Normal acuity Patient complains of pleuritic chest pain
Psychological Needs Increased acuity No indication at this time
Neurological Normal acuity No indication at this time
You correctly diagnosed 7 out of 7 options:
Physiological
Description Your Response
Acute pain True Patient complains of pleuritic chest pain
Bleeding, risk for False No indication at this time
Impaired mobility, risk for False No indication at this time
Nausea False No indication at this time
Safety
DescriptionYour
Response
Deficient knowledge True Patient needs HIV spread prevention education, and current treatments available
Grieving False No indication at this time
