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Donald Lyles - ANSWER-Educational - increased Fall Risk - normal Health Change - increased Neurological - normal Pain - normal Psychological Needs - normal Donald Lyles - ANSWER-Scenario #1 Establish responsiveness Call for code Check for breathing
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Donald Lyles - ANSWER-Educational - increased Fall Risk - normal Health Change - increased Neurological - normal Pain - normal Psychological Needs - normal Donald Lyles - ANSWER-Scenario # Establish responsiveness Call for code Check for breathing Begin continuous When help arrives Scenario # Assist with airway Assist with applying Establish large IV Provide pt. hx Provide medical hx Scenario # Check time Establish when the cardiac Document rhythm Begin list of medications
Remind CODE Karen Cole - ANSWER-Educational - increased Fall Risk - normal Health Change - increased Pain - normal Psychological Needs - normal Sensorium - normal Kate Bradley - ANSWER-Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Neurological - increased Sarah Getts - ANSWER-Educational - increased Fall Risk - increased Health Change - increased Pain - normal Psychological Needs - increased Sensorium - increased Mark Robinson - ANSWER-Educational - increased Fall Risk - increased Health Change - increased Neurological - normal Pain - increased Psychological Needs - normal
Health Change - increased Pain - increased Psychological Needs - normal Sensorium - increased Nathaniel Gonzalez - ANSWER-Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Neurological - normal Wight Goodman - ANSWER-Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Neurological - increased Ann Rails - ANSWER-Educational - Increased Fall Risk - Increased Health Change - Increased Pain - Increased Psychological Needs - Increased Dana Fitzgerald - ANSWER-Educational - increased Fall Risk - normal Health Change - increased Pain - increased Psychological Needs - normal
Neurological - normal Dana Fitzgerald - ANSWER-Knowledge deficit Potential for grief Potential for infection Mark Robinson - ANSWER-Alteration in comfort Potential for bleeding Knowledge deficit Potential for acute substance withdrawal syndrome Nathaniel Gonzalez - ANSWER-Acute discomfort Knowledge deficit Potential for falls Sarah Getts - ANSWER-Electrolyte imbalance Ineffectual renal perfusion, risk for Potential for imbalanced fluid volume Acute confusion Potential for falls Failure to thrive Karen Cole - ANSWER-Alteration in ability to cope Potential for impaired comfort Potential for injury Kate Bradley - ANSWER-Acute discomfort Alteration in comfort Alteration in mobility Potential for bleeding Knowledge deficit
Notify Dr. and charge nurse Scenario # Remind physician Explain to physician Assist physician Obtain recent Reassure pt. Scenario # Tap pt. Elevate HOB Call rapid response Start secondary Remain with pt. Scenario # Provide verbal report Emergency intubation Assume role Obtain pt. record Provide information Scenario # You explain that his condition You explain that he is receiving You have them remain with you You escort them with you You call his doctor ASSISTANCE REQUESTED
Patient in the next room states, "My IV tubing is tangled in the bed rail." - ANSWER-LPN ASSISTANCE REQUESTED Patient tells family, "I need my urinal emptied." - ANSWER-CNA ASSISTANCE REQUESTED You hear a patient screaming, "My IV site is burning me now." - ANSWER-RN ASSISTANCE REQUESTED Call light on. No answer from patient. - ANSWER-CNA ASSISTANCE REQUESTED You hear a patient moaning, "I'm too hot. Do something!" - ANSWER-CNA ASSISTANCE REQUESTED Patient in other room states, "I would like to speak to your chaplain." - ANSWER-CNA ASSISTANCE REQUESTED Patient in the next room states, "My dressing just came off and I need it back on." - ANSWER-LPN ASSISTANCE REQUESTED A patient states, "I'm having the worst headache of my life!" - ANSWER-RN ASSISTANCE REQUESTED Patient cries, "My pain is worse now! Do something!" - ANSWER-LPN Chanthavy Chhet - ANSWER-Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased
Health Change - increased Pain - increased Psychological Needs - normal Sensorium - normal Julia Monroe - ANSWER-Education Needs - increased Fall Risk - increased Health Change - increased Neurological - normal Pain - increased Psychological - normal Kathy Gestalt - ANSWER-Educational - increased Fall Risk - increased Health Change - increased Pain - normal Psychological Needs - increased Sensorium - normal Ruth Cummings - ANSWER-Educational - increased Fall Risk - increased Health Change - increased Pain - increased Psychological Needs - increased Neurological - normal Chanthavy Chhet - ANSWER-Acute discomfort Nausea Potential for alteration in mobility Alteration in verbal communication Cultural competence
Knowledge deficit Don Johnson - ANSWER-Acute discomfort Potential for alteration in electrolyte balance Potential for altered body image Potential for audiology changes Potential for PTSD Potenial for infection Julia Monroe - ANSWER-Acute discomfort Alteration in comfort Alteration in mobility Potential for falls Ramona Stukes - ANSWER-Alteration in mobility Potential for bleeding Potential for decrease in fluid volume Potential for falls Potential for infection John Duncan - ANSWER-Decrease in fluid volume Exhaustion Potential for alteration in electrolyte imbalance Potential for falls Noncompliance Wight Goodman - ANSWER-Scenario # Wash hands & assess Complete neuro Check the blood Pre-op education
Obtain translator Initiate IV Begin antibiotics Consult MD Contact family Scenario # What is going on? We need to stop the bleeding Tell me where you are Who were you talking to? What were the voices telling you? Scenario # Attempt to establish rapport Notify HCP of findings Clean patient and attempt to restart IV Contact dietary Obtain a sitter Remove potential harmful objects Scenario # Delay insertion of IV Contact HCP Contact CC's uncle Request the uncle come Request the uncle participates Scenario # Provide one-to-one Initiate anti-psychotic meds
Ensure family member Reassess environment Initiate continuous observation Don Johnson - ANSWER-Scenario # Complete full assessment Insert foley Initiate IV Apply Silvadene Contact HCP Scenario # Reassess lung sounds Empty foley bag Administer pain meds Notify HCP Document Scenario # Elevate HOB Assess pt's sputum Reassure the pt. Assure the pt. Contact respiratory therapy Scenario # Obtain doppler pulse Adjust rate of IV Ask for available tech Change dressing Determine if the pt.
Establish an IV Administer digoxin Monitor for adverse Request repeat Scenario # Check leads Perform Start O Call RRT Educate pt Ramona Stukes - ANSWER-Scenario # Wash & glove Full assessment Allow expression Educate pt. Evaluate understanding Scenario # Wash & glove Full assessment Check NG tube Administer IV antiemetic Scenario # Full assessment Educate pt. Evaluate understanding Notify lead RN Consult wound care
Scenario # Discuss w/ pt. Notify lead RN Contact social services Update pt. Scenario # Follow HIPAA Explain HIPAA Offer resource Contact wound care Document Kathy Gestalt - ANSWER-Scenario # Check pedal cap refill Educate pt. Evaluate understanding Adjust crutches Assist pt. OOB Scenario # Wash & glove VS assessment Administer anit-pyretics Verify call light Document results Scenario # Inspect cast site Assess toe movement
Scenario # Ask Ensure Take VS Check for IV Disconnect Scenario # Receive Assess/inspect Elevate Take VS Give pt Scenario # Assist pt Ensure Notify charge nurse Notify HCP Complete John Duncan - ANSWER-Scenario # Assess I&O Construct dietary consult Acquire daily weight Evaluate outcome Scenario # Full assessment Check I&O Teach pt. about safety
Document Scenario # Wash/glove hands Provide emesis basin VS assessment Administer antiemetic Evaluate medication Scenario # VS assessment Assessment of bowel Administer protocol Document results Include pt. condition Scenario # Inform & educate spouse Evaluate/modify Assess food Document Cameron Daniels - ANSWER-Scenario # Give tylenol Start another IV Initiate bolus Request additional pain med Reasses temp in 1 hour Scenario # Sit at an eye level