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A Complete Solution on vSim for Nursing | Medical-Surgical

SURGICAL SCENARIOS FOR STAN CHECKETTS
1. Document your focused assessment of Stan Checketts’ abdomen.
2. Document immediate priority actions related to the treatment of hypovolemic shock.
3. Document the changes in Stan Checketts’ vital signs throughout the scenario.
4. Identify and document key nursing diagnoses for Stan Checketts.
5. Referring to your feedback log, document the nursing care you provided.

ANSWER
1. Document your focused assessment of Stan Checketts’ abdomen.
I auscultated the patient abdomen; patient had hyperactive sounds, ask about his pain, patient has cramping type of pain in the stomach. Any movement make the pain worse, and vomiting provides some type of temporary relieve.
Vital signs
Heart rate: 129
Pulse: present and strong
Blood pressure: 107/ 77 mmHg
Respiration: 29
Conscious state: Alert and oriented X3
SpO2: 99
Temperatures: 99

2. Document immediate priority actions related to the treatment of hypovolemic shock.
I administered fluid, normal saline. 500mL/ 30 mins which I would calculate and set the pump to 1000mL /h. Administered oxygen

3. Document the changes in Stan Checketts’ vital signs throughout the scenario.
Patient vital signs have not changed significantly through the scenario, I was surprised that the BP did not improved however, the SpO2 improved

4. Identify and document key nursing diagnoses for Stan Checketts.
-Fluid and electrolytes imbalance related to vomiting evidenced by decrease in blood pressure, increase in heart rate , and increase in hematocrit
-Acute pain related to bowel obstruction evidenced by increased heart and respiratory rate and facial expressions
-Nausea related to gastrointestinal irritation as evidenced by vomiting and patient statement .

5. Referring to your feedback log, document the nursing care you provided
-I washed your hands.
-I identified the patient.
-I obtained IV access in the arm. It’s correct to obtain IV/IO access here.
-I started a bolus of 500 mL normal saline, given over 30 minutes.
-I attached a 3-lead ECG. It is correct to attach the monitor to the patient.
-I attached the automatic noninvasive blood pressure (NIBP) measurement cuff.
-I placed a nasogastric tube.
-I attached the pulse oximeter. It is a good idea to monitor the saturation and pulse here. This will allow you to reassess the patient continuously.
-I checked the temperature at the mouth. The temperature was 99 F (37 C).
-I measured the blood pressure at 110/78 mm Hg.
-I obtained informed consent.
-I requested an abdominal x-ray.
-I looked for normal breathing. He is breathing at 28 breaths per minute. The chest is moving normally on both sides.
-I asked the patient if he had any pain. He replied: ‘Yes, I have some pain.’
-I asked the patient if anything made the pain better. He replied: ‘Vomiting makes me feel less bloated for a short time.’
-I asked the patient if anything made the pain worse. He replied: ‘Any movement really’
-I asked the patient if he could describe his pain. He replied: ‘It’s a cramping kind of pain in my stomach.’
-I asked the patient where the pain was located. He replied: ‘It’s in my stomach.’
-I asked the patient if the pain went anywhere. He replied: ‘No, not really.’
-I asked: How bad is the pain? He replied: ‘Not too bad, it’s about a 4.’
-I asked the patient how long he had pain for. He replied: ‘A few days’
-I asked the patient if the pain was better after the medication. He replied: ‘It’s the same.’
-I provided patient education. This is correct. It is important to use every opportunity to provide patient education.

 

Description

SURGICAL SCENARIOS FOR STAN CHECKETTS
1. Document your focused assessment of Stan Checketts’ abdomen.
2. Document immediate priority actions related to the treatment of hypovolemic shock.
3. Document the changes in Stan Checketts’ vital signs throughout the scenario.
4. Identify and document key nursing diagnoses for Stan Checketts.
5. Referring to your feedback log, document the nursing care you provided.

ANSWER
1. Document your focused assessment of Stan Checketts’ abdomen.
I auscultated the patient abdomen; patient had hyperactive sounds, ask about his pain, patient has cramping type of pain in the stomach. Any movement make the pain worse, and vomiting provides some type of temporary relieve.
Vital signs
Heart rate: 129
Pulse: present and strong
Blood pressure: 107/ 77 mmHg
Respiration: 29
Conscious state: Alert and oriented X3
SpO2: 99
Temperatures: 99

2. Document immediate priority actions related to the treatment of hypovolemic shock.
I administered fluid, normal saline. 500mL/ 30 mins which I would calculate and set the pump to 1000mL /h. Administered oxygen

3. Document the changes in Stan Checketts’ vital signs throughout the scenario.
Patient vital signs have not changed significantly through the scenario, I was surprised that the BP did not improved however, the SpO2 improved

4. Identify and document key nursing diagnoses for Stan Checketts.
-Fluid and electrolytes imbalance related to vomiting evidenced by decrease in blood pressure, increase in heart rate , and increase in hematocrit
-Acute pain related to bowel obstruction evidenced by increased heart and respiratory rate and facial expressions
-Nausea related to gastrointestinal irritation as evidenced by vomiting and patient statement .

5. Referring to your feedback log, document the nursing care you provided
-I washed your hands.
-I identified the patient.
-I obtained IV access in the arm. It’s correct to obtain IV/IO access here.
-I started a bolus of 500 mL normal saline, given over 30 minutes.
-I attached a 3-lead ECG. It is correct to attach the monitor to the patient.
-I attached the automatic noninvasive blood pressure (NIBP) measurement cuff.
-I placed a nasogastric tube.
-I attached the pulse oximeter. It is a good idea to monitor the saturation and pulse here. This will allow you to reassess the patient continuously.
-I checked the temperature at the mouth. The temperature was 99 F (37 C).
-I measured the blood pressure at 110/78 mm Hg.
-I obtained informed consent.
-I requested an abdominal x-ray.
-I looked for normal breathing. He is breathing at 28 breaths per minute. The chest is moving normally on both sides.
-I asked the patient if he had any pain. He replied: ‘Yes, I have some pain.’
-I asked the patient if anything made the pain better. He replied: ‘Vomiting makes me feel less bloated for a short time.’
-I asked the patient if anything made the pain worse. He replied: ‘Any movement really’
-I asked the patient if he could describe his pain. He replied: ‘It’s a cramping kind of pain in my stomach.’
-I asked the patient where the pain was located. He replied: ‘It’s in my stomach.’
-I asked the patient if the pain went anywhere. He replied: ‘No, not really.’
-I asked: How bad is the pain? He replied: ‘Not too bad, it’s about a 4.’
-I asked the patient how long he had pain for. He replied: ‘A few days’
-I asked the patient if the pain was better after the medication. He replied: ‘It’s the same.’
-I provided patient education. This is correct. It is important to use every opportunity to provide patient education.

 

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SURGICAL SCENARIOS FOR STAN CHECKETTS
1. Document your focused assessment of Stan Checketts’ abdomen.
2. Document immediate priority actions related to the treatment of hypovolemic shock.
3. Document the changes in Stan Checketts’ vital signs throughout the scenario.
4. Identify and document key nursing diagnoses for Stan Checketts.
5. Referring to your feedback log, document the nursing care you provided.

ANSWER
1. Document your focused assessment of Stan Checketts’ abdomen.
I auscultated the patient abdomen; patient had hyperactive sounds, ask about his pain, patient has cramping type of pain in the stomach. Any movement make the pain worse, and vomiting provides some type of temporary relieve.
Vital signs
Heart rate: 129
Pulse: present and strong
Blood pressure: 107/ 77 mmHg
Respiration: 29
Conscious state: Alert and oriented X3
SpO2: 99
Temperatures: 99

2. Document immediate priority actions related to the treatment of hypovolemic shock.
I administered fluid, normal saline. 500mL/ 30 mins which I would calculate and set the pump to 1000mL /h. Administered oxygen

3. Document the changes in Stan Checketts’ vital signs throughout the scenario.
Patient vital signs have not changed significantly through the scenario, I was surprised that the BP did not improved however, the SpO2 improved

4. Identify and document key nursing diagnoses for Stan Checketts.
-Fluid and electrolytes imbalance related to vomiting evidenced by decrease in blood pressure, increase in heart rate , and increase in hematocrit
-Acute pain related to bowel obstruction evidenced by increased heart and respiratory rate and facial expressions
-Nausea related to gastrointestinal irritation as evidenced by vomiting and patient statement .

5. Referring to your feedback log, document the nursing care you provided
-I washed your hands.
-I identified the patient.
-I obtained IV access in the arm. It’s correct to obtain IV/IO access here.
-I started a bolus of 500 mL normal saline, given over 30 minutes.
-I attached a 3-lead ECG. It is correct to attach the monitor to the patient.
-I attached the automatic noninvasive blood pressure (NIBP) measurement cuff.
-I placed a nasogastric tube.
-I attached the pulse oximeter. It is a good idea to monitor the saturation and pulse here. This will allow you to reassess the patient continuously.
-I checked the temperature at the mouth. The temperature was 99 F (37 C).
-I measured the blood pressure at 110/78 mm Hg.
-I obtained informed consent.
-I requested an abdominal x-ray.
-I looked for normal breathing. He is breathing at 28 breaths per minute. The chest is moving normally on both sides.
-I asked the patient if he had any pain. He replied: ‘Yes, I have some pain.’
-I asked the patient if anything made the pain better. He replied: ‘Vomiting makes me feel less bloated for a short time.’
-I asked the patient if anything made the pain worse. He replied: ‘Any movement really’
-I asked the patient if he could describe his pain. He replied: ‘It’s a cramping kind of pain in my stomach.’
-I asked the patient where the pain was located. He replied: ‘It’s in my stomach.’
-I asked the patient if the pain went anywhere. He replied: ‘No, not really.’
-I asked: How bad is the pain? He replied: ‘Not too bad, it’s about a 4.’
-I asked the patient how long he had pain for. He replied: ‘A few days’
-I asked the patient if the pain was better after the medication. He replied: ‘It’s the same.’
-I provided patient education. This is correct. It is important to use every opportunity to provide patient education.