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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: