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: