Surgical Case 3: Doris Bowman Documentation Assignments 1. Document Doris Bowman’s vital signs that occurred in the case. Beginning of the scenario: Patient status - ECG: Sinus tachycardia. Heart rate: 111. Pulse: Present. Blood pressure: 153/92 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 93%. Temp: 99 F (37 C)
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While taking 1st set of vitals: Patient status - ECG: Sinus tachycardia. Heart rate: 109. Pulse: Present. Blood pressure: 150/90 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C) After giving 2mg of Morphine: Patient status - ECG: Sinus rhythm. Heart rate: 94. Pulse: Present. Blood pressure: 134/80 mm Hg. Respiration: 7. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C) After giving 0.2mg of Naloxone: Patient status - ECG: Sinus rhythm. Heart rate: 91. Pulse: Present. Blood pressure: 119/67 mm Hg. Respiration: 12. Conscious state: Somnolent. SpO2: 95%. Temp: 99 F (37 C
After calling the doctor: Patient status - ECG: Sinus tachycardia. Heart rate: 105. Pulse: Present. Blood pressure: 141/78 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C)
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2. Document the actions that should be taken when Doris Bowman’s severe respiratory depression occurs. Provide appropriate oxygenation and ventilation. Calling for help so that those actions can be done quickly and efficiently. Since this is caused by Morphine, administering Naloxone is done. It treats narcotic overdose in an emergency situation. It’s important to monitor the patient’s airway and ventilation. Per the doctor’s order I could give another 0.2mg of Naloxone every 2 minutes if her respiration was less than 8.
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3. Document the airway management that occurred during the scenario. Provided ventilation with the Code team. 10L at 10 breaths per minute. Checked respirations and monitored O2 saturation every 2 minutes.
4. Identify and document key nursing diagnoses for Doris Bowman. Ineffective breathing pattern Impaired gas exchange
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Fatigue Activity intolerance Deficient knowledge Risk for infection Risk for bleeding Risk for falls/injury Impaired skin integrity Impaired tissue integrity Nausea Acute pan 5. Referring to your feedback log, document the nursing care you provided and Doris Bowman’s response.
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Feedback Log
You arrived at the patient's side.
0:00
You introduced yourself.
0:05
You washed your hands. To maintain patient safety, it is important to wash your hands as soon as you enter the room.
0:10
Patient status - ECG: Sinus tachycardia. Heart rate: 111. Pulse: Present. Blood pressure: 153/92 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 93%. Temp: 99 F (37 C)
1:10
Patient status - ECG: Sinus tachycardia. Heart rate: 110. Pulse: Present. Blood pressure: 153/91 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 94%. Temp: 99 F (37 C)
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0:00
You identified the patient. To maintain patient safety, it is important that you quickly identify the patient.
1:37
You attached a 3-lead ECG. It is correct to attach the monitor to the patient.
1:54
You 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.
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1:18
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You measured the blood pressure at 150/90 mm Hg. It is appropriate to monitor the patient by measuring the blood pressure.
2:10
Patient status - ECG: Sinus tachycardia. Heart rate: 109. Pulse: Present. Blood pressure: 150/90 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C)
2:37
You checked the temperature at the mouth. The temperature was 99 F (37 C).
2:46
You looked for normal breathing. She is breathing at 21 breaths per minute. The chest is moving normally on both sides.
3:10
Patient status - ECG: Sinus tachycardia. Heart rate: 108. Pulse: Present. Blood pressure: 150/90 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C)
3:20
You assessed the patient's dressing. This is correct. Assessing any dressings the patient has is always important.
3:40
You examined the patient's abdomen and pelvis. There is a 4x4 gauze dressing with no drainage. There is nothing else to find on examination of the abdomen and pelvis. There is normal skin turgor. Her skin is cool, and she is very sweaty.
4:10
Patient status - ECG: Sinus tachycardia. Heart rate: 108. Pulse: Present. Blood pressure: 153/91 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C)
5:02
You listened to the abdomen of the patient. You could hear hypoactive sounds from the abdomen. This is reasonable.
5:10
Patient status - ECG: Sinus tachycardia. Heart rate: 108. Pulse: Present. Blood pressure: 150/89 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C)
6:09
You asked if the patient was allergic to anything. She replied: 'No, I am not allergic to anything.'
6:10
Patient status - ECG: Sinus tachycardia. Heart rate: 108. Pulse: Present. Blood pressure: 151/90 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C)
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2:10
You assessed the patient's IV. The site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact. This is correct. Assessing any IVs the patient has is always important.
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6:22
7:10
Patient status - ECG: Sinus tachycardia. Heart rate: 108. Pulse: Present. Blood pressure: 150/90 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C)
7:37
You asked the patient if she had any pain. She replied: 'Yes! Ahh...'
7:42
You asked: How bad is the pain? She replied: 'It's pretty bad, I'd give it
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a 6.' You asked the patient where the pain was located. She replied: 'It's in my stomach.'
8:07
A 2 mg dose of morphine was injected IV. It was reasonable to give an opioid here. It is important to use the basic rights of medication administration to ensure proper drug therapy..
8:08
The patient started developing respiratory depression.
8:10
Patient status - ECG: Sinus tachycardia. Heart rate: 108. Pulse: Present. Blood pressure: 151/91 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C)
8:18
You flushed the cannula.
8:20
Patient status - ECG: Sinus tachycardia. Heart rate: 103. Pulse: Present. Blood pressure: 145/87 mm Hg. Respiration: 15. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C)
8:30
Patient status - ECG: Sinus rhythm. Heart rate: 94. Pulse: Present. Blood pressure: 134/80 mm Hg. Respiration: 7. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C)
8:31
You looked for normal breathing. She is breathing at 7 breaths per minute. The chest is moving normally on both sides.
8:49
The patient's respiration rate dropped below 6 breaths per minute.
8:51
Patient status - ECG: Sinus rhythm. Heart rate: 90. Pulse: Present. Blood pressure: 122/72 mm Hg. Respiration: 5. Conscious state: Somnolent. SpO2: 94%. Temp: 99 F (37 C)
8:52
You looked for normal breathing. She is breathing at 5 breaths per minute. The chest is not moving very well.
9:06
You activated the code team. It was reasonable to activate the code team at this point.
9:17
You started assisting a patient who was breathing. You were able to provide sufficient ventilation.
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7:50
You administered 0.2 mg of naloxone IV. Naloxone is the appropriate drug to give here to reverse the effect of the opioid.
9:44
You flushed the cannula.
9:50
Patient status - ECG: Sinus rhythm. Heart rate: 91. Pulse: Present. Blood pressure: 119/67 mm Hg. Respiration: 12. Conscious state: Somnolent. SpO2: 95%. Temp: 99 F (37 C)
9:58
You looked for normal breathing. She is breathing at 13 breaths per
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9:39
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minute. The chest is moving normally on both sides. Patient status - ECG: Sinus rhythm. Heart rate: 91. Pulse: Present. Blood pressure: 118/66 mm Hg. Respiration: 15. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C)
10:1 1
You stopped ventilating the patient.
10:1 5
You asked the patient if she was awake. She replied: 'I'm awake.'
10:1 8
Patient status - ECG: Sinus rhythm. Heart rate: 99. Pulse: Present. Blood pressure: 126/71 mm Hg. Respiration: 20. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C)
10:1 9
You asked the patient if she knew where she was. She replied: 'I'm at the hospital.'
10:2 8
You provided patient education. This is correct. It is important to use every opportunity to provide patient education.
10:4 5
You looked for normal breathing. She is breathing at 21 breaths per minute. The chest is moving normally on both sides.
11:0 8
You phoned the provider in order to discuss the patient.
11:1 8
Patient status - ECG: Sinus tachycardia. Heart rate: 105. Pulse: Present. Blood pressure: 141/78 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C)
12:1 8
Patient status - ECG: Sinus tachycardia. Heart rate: 106. Pulse: Present. Blood pressure: 139/77 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C)
13:1 8
Patient status - ECG: Sinus tachycardia. Heart rate: 106. Pulse: Present. Blood pressure: 139/77 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C)
13:1 9
A patient handoff was performed.
Nursing management objectives for the patient in the post anesthesia care unit are to provide care until the patient has recovered from the effects of anesthesia, is oriented, has stable vital signs, and shows no evidence of complications. Pain control is a critical component of postoperative care and often includes IV opioid analgesic medications to provide immediate but short-acting pain relief. The most common adverse effects of opioid analgesic agents are constipation, nausea, vomiting, pruritus, and sedation. Respiratory depression is a less common but serious adverse effect. Prevention of clinically significant opioid-induced respiratory depression begins with administration of
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10:0 0
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the lowest effective opioid dose, careful titration, and close nurse monitoring of sedation and respiratory status throughout therapy. If respiratory depression occurs, the nurse provides appropriate oxygenation and ventilation and calls for help.
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You got 100%
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