Daniel Perlas Semester 3 ASSESSMENTS!!! 1.

) Age- 76 (geriatric) Gender: Male, POD1 Sx- Total Hip replacement Anesthetic: Spinal 02: 3L/min IV- calculated before scenario (MICRODRIP) 75cc/1hr (60 min.) x 60gtts/ml= 75 gtts/min.= 75/4= 19 gtts/ 15 sec. D51/2NS infusing on RFA Ins- hemovac Out- Foley catheter in situ Medications- Dalteparin- 5000 IU SC QD X 10 days (see drug card) Ancef- 1 gm IV pre-op (see drug card) ASSESSMENTS: Reposition- maintain alignment, dont turn on affected side (draw sheet needs to be changed) Teaching- DB & C & leg exercises, MAINTAIN ABDUCTION (no more than 90 deg.)

2.) Age- 35, Gender: Female, POD2 Sx- Colectomy anesthetic- general anesthesia (Loc, LOO and ABC & RR and BS- passing GAS IN THE BAG, should be ok d/t POD2) 02- 4L/ min. Via NP NG- tube suction- turn off but needs doctor order for that d/t low continuous suction- 40-80 mmHg IV- calculated before scenario (Macrodrip)150 cc/1hr (60 min.)X 10 gtts/ml= 25 gtts/min.= 25/4= 6 gtts/ 15 sec. D5NS infusing on RFA. Outs- Ileostomy- a bit bleeding, bag needs to be drained, Foley catheter in situ Medications- Ranitidine- 50 mg PO TID (see drug card) Morphine- 4-6 mg IV q3-4 h PRN (see drug card)RN Shut off NG suction for 30 min. Give it & wait for 30 min. To re-asses if pt. tolerating the ranitidine. ASK pt. for distention/ N&V ASSESSMENTS: Drain ileostomy bag Teaching- DB & C (splint) & Leg exercise how to empty the ileostomy bag

3.) Age- 61, Gender: Male, POD0 [6 hours] Sx- TURP, CBI asmts anesthesia- spinal (SHOULD BE WORN OUT But still assess dermatomes bec. it worn out 2-3 hours (just a few hours gap 2 vs. 6) Ins- 02- 2L/ min. Via NP IV- calculated before scenario (Macrodrip)125 cc/1hr (60 min.)X 10 gtts/ml= 21 gtts/min.= 21/4= 5 gtts/ 15 sec. D5W on RUA. (dextrose in water) Outs- CBI in situ C. Diff. - contact precaution (REVIEW DIFFERENT TYPES OF CONTACT PREC.) Medications- B & O supp. Q6h PR prn for pain (see drug card) [Narcotic sheet] *NEVER USE SUPP. IF PATIENT HAS DIARRHEA. ASK FOR LBM/ constipation!! Also in every scenarios* Flagyl- 500 mg PO bid (see drug card) ASSESSMENTS: Assess returns for CBI Teaching- DB no C (avoid straining for CBI) & Leg exercise, and ask pt. to Bed rest and avoid 90 deg. Lying on bed *to prevent pressure on the prostate* 4.) Age- 30 years old, Gender: Female, POD0 [D.O.: 2 UNITS OF PACKED RBC] (INITIAL SCENARIO SMOKING CESSATION TEACHING) Sx- C-sec. anesthesia- spinal (10 hours ago) ASK about headache, I could check dermatomes even if it worn out already heavy smoker- RISK for PNEUMONIA FOCUS- RESPIRATORY Ins- 02- 2L/min. via NP IV- calculated before scenario (Macrodrip)75 cc/1hr (60 min.)X 10 gtts/ml= 13 gtts/min.= 13/4= 3 gtts/ 15 sec. 2/3 1/3 on RFA. (2/3 dextrose & 1/3 Normal Saline) Outs- foley catheter in situ Medications- Pitocin 10 Units IM for post partum hemorrhage (see drug card) [OXYTOCIN] *monitor urinary retention* Tylenol # 3 i- ii tabs q4h (see drug card) [narcotic sheet]

ASK FOR LBM/ constipation!! Also in every scenarios

ASSESSMENTS: Teaching- DB & C (splint) & Leg exercise, and teach about the hemorrhage (lochia stage) PERI PAD CHANGE -- CLOT/ PLACENTA PART ASSESS blood transfusion reaction KNOW LPN ROLE (potential complic. Haemolytic, anaph. febrile) 5.) Age: 84 years old (geriatric), Gender: female, POD 3 (Pt. abd. wound 30 day old with MSA from inguinal hernia) Dx: CVA with left side weakness (neuro assessments) IV: D51/2 infusing @ 75cc/hr via RFA (micro) O2 runing 3L/min. via NP Foley catheter ABD wound + MRSA MEDS: Plavix- 75 mg PO Vancomycin- 500 mg IV (ASSIST to BEDPAN, BRING EXTRA SOAKER PAD AND LOTS OF GLOVES INSIDE A garbage bag) Plan of care 1 1.) Check D.O., MICRODRIP----calculate drip rate- 75 gtts/min or 19 gtts/15 sec., check age, weight, post op day and type of sx? dx, anesthetics?tubings? incisions? THEN WASH HANDS 2.) Gather supplies include draw sheet and extra pillows, neurovascular sheet, extra paper and pen, garbage bag and tape, stethoscope, temperature and O2 stat 3.) INTRODUCE SELF AND GLANCE PATIENT POSITIONING; SHOULD BE SEMI FOWLER AS LONG AS ITS NOT LESS THAN 90 deg. HOB elevated, Safety (bed brakes, appropriate bed height, call bell within reach no obstruction) QUICKLY CHECK IF O2 are working, IV and other devices --- PRIVACY 4.) Do a head to toe asmt (follow guidelines) Focus asmts:

Hemovac- sang, serosang,purulent? Incision- pooling of blood and shadowing NEUROVASCULAR ASMTS Maintaining abduction (away from the midline) with abductor pillows 5.) Ask for help when repositioning the patient, explain the procedure to the patient and (CALL SARAH) & DONT POSITION THE PATIENT ON HIS AFFECTED SIDE, make sure no KINKS ON TUBING 6.) Teach patient to D B and C. Make sure patient wiggle/move his toes and reposition himself q2h. Maintain abductor pillow and teach not to cross the midline, and do not sit less than 90 deg. Teach about the catheter care. When getting up press the call bell. 7.) administer medication (dalteparin) [do the checks prelim and 3 checks]. 8.) SAFETY AGAIN

Plan of care 2 1.) Check D.O.--- ORDER for LOW CONTINUOUS SUCTION DISCONT. (40-80 mmhg), MACRODRIP----calculate drip rate- 25 gtts/min or 6 gtts/15 sec., check age, weight, dx, post op day and type of sx? anesthetics?tubings? incisions? THEN WASH HANDS 2.) Gather supplies extra paper and pen, splint pillow, deodorizer!!, stethoscope, garbage bag, tape, temperature and O2 stat, cylinder, blue pad, tissue (underneath the drawer) 3.) INTRODUCE SELF AND GLANCE PATIENT POSITIONING; SHOULD BE FOWLERS AS LONG AS SHE`S NOT ON SUPINE, Safety (bed brakes, appropriate bed height, call bell within reach no obstruction) QUICKLY CHECK IF O2 are working, IV, NG suction and other devices --- PRIVACY 4.) Do a head to toe asmt (follow guidelines) Focus asmts: NG-SUCTION--- make sure its pinned to pt. and WRITE the total amount on tape; Make sure dont forget to TURN IT ON AFTER CHEST AUSCULTATION AND BS AND KEEP ASKING FOR N&V!! GI asmts: Nausea and vomiting or distention ABD Incision- charac. And pooling of blood and shadowing BOWEL SOUNDS present

STOMA ASMTS (Beefy RED, MOIST, Warmth, BULGE and slight bleeding) Check bag if been passing gas and for any leakage 5.) While draining ostomy bag, make sure to do health teaching on how to empty it with deodorizer or who to talk with (OSTOMY NURSE)!! 6.) Teach patient to D B and C with splinting and while moving. Make sure patient wiggle/move his toes and reposition himself q2h. Teach about the catheter care. When getting up press the call bell. 7.) administer medication (ranitidine) [do the checks prelim and 3 checks]. (give med. Wait for 30 min., then turn on the suction afterwards to see if pt. tolerating med.) IF PATIENT NOT TOLERATING IT, NOTIFY RN if it`s possible to get an IV for ranitidine or call pharmacy to get IM GRAVOL or check NIO 8.) SAFETY AGAIN

Plan of care 3 1.) Check D.O.---D/C CBI and change into straight drainage [rate is fast, moderate or slow???], TAKE B AND O supp. with LUBRICANT to be put in the bag MACRODRIP----calculate drip rate- 21 gtts/min.= 21/4= 5 gtts/ 15 sec. , check age, weight, dx, post op day and type of sx? anesthetics?tubings? incisions? THEN WASH HANDS 2.) Gather supplies STERILE PLUG AND CAP, alcohol swabs, bunch of CLEAN GLOVES inside the GARBAGE BAG, extra paper (verbalized the template for v/s sheet) and dedicated pen, cylinder measurement, BLUE GARBAGE bin, dedicated stethoscope and BP machine, MAKE SURE theres A CLOCK, garbage bag, tape, temperature and O2 stat, blue pad [make sure to wear gown and gloves] 3.) INTRODUCE SELF AND GLANCE PATIENT POSITIONING; SHOULD BE Supine or 10 to 15 deg. AS LONG AS Hes NOT ON HIGH FOWLERS, Safety (bed brakes, appropriate bed height, call bell within reach no obstruction) QUICKLY CHECK IF O2 are working, IV, CBI is on the same side as the drainage bag and other devices --- PRIVACY 4.) Do a head to toe asmt (follow guidelines) Focus asmts: PAIN- PQRST, CBI asmts, CBI TUBINGS, DRIP chamber (FAST, moderate or slow),ASK for PRESSURE in the bladder/ assess for

distention???? CBI RETURNS [PINK, dark pink or red] urine characteristics after d/c?? 5.) While draining the returns, assess if reddish or pink? Urine is assessed in the catheter tubing 6.) Teach patient to D B and NO COUGHING. Make sure patient wiggle/move his toes and reposition himself q2h. Teach about the catheter care. When getting up to the washroom and notice frank blood on bag, teach patient to go back to bed, press the call bell and CBI needs to be administer again to prevent hemorrhaging. INCREASE FLUID INTAKE about 2-3 L of fluids a day and avoid straining when you go to the washroom 7.) administer medication (B and O supp.) OPTIONAL if not done in the begin. 8.) SAFETY AGAIN

Plan of care 4 1.) Check D.O.---- CHECK FOR CORRECT BLOOD TYPING AND CROSS MATCHING, RHESUS factor, CHECK BASELINE V/S d/t BLOOD TRANSFUSION, MACRODRIP----calculate drip rate- 75 cc/1hr (60 min.)X 10 gtts/ml= 13 gtts/min.= 13/4= 3 gtts/ 15 sec., CALCULATE DRIP RATE FOR BLOOD TRANSFUSION: check age, weight, dx, post op day and type of sx? anesthetics?tubings? incisions? THEN WASH HANDS 2.) Gather supplies, TONGUE depressor, EXTRA PERI PAD with mesh underwear, bunch of CLEAN GLOVES, extra paper and pen, cylinder measurement, BLUE GARBAGE bin, stethoscope, garbage bag, tape, temperature and O2 stat, blue pad 3.) INTRODUCE SELF AND GLANCE PATIENT POSITIONING; SHOULD BE ON SEMI FOWLERS, If baby present, put the baby on crib, CHECK ID BAND or MAKE pt. VERBALIZE name, Safety (bed brakes, appropriate bed height, call bell within reach no obstruction) QUICKLY CHECK FOR QPA PT. REACTION to blood transfusion?? IF O2 are working, IV Normal Saline hanging in case of emer., and other devices --- PRIVACY 4.) Do a head to toe asmt (follow guidelines)

Focus asmts: INCISION PAIN- PQRST or INCISION DISCHARGE??, ASSESS BUBBLE HEE, REEDA??, MASTITIS? LOCHIA assessments using tongue depressor [BEST TO TEACH CLIENT about what to report on lochias]! ASK for PRESSURE in the bladder/ assess for distention???? ASSESS UTERUS if in the midline 5.) Foley asmts Urine is assessed in the catheter tubing 6.) Teach patient to D B and COUGHING with splint. Teach patient that within 3rd day, colostrum will be there and notice that breast is getting firm is normal, if you have more ?s, I can refer you to lactating nurse , Make sure patient wiggle/move his toes and reposition himself q2h. Teach about the catheter care. 7.) administer medication (Tylenol # 3 or pitocin for emergency) 8.) SAFETY AGAIN Plan of care 5 1.) Check D.O.--- ischemic CVA Lt. Side weakness, MACRODRIP----75 cc/1hr (60 min.)X 10 gtts/ml= 13 gtts/min.= 13/4= 3 gtts/ 15 sec. , check age, weight, dx, post op day and type of sx? anesthetics?tubings? incisions? THEN WASH HANDS 2.) Gather supplies, bunch of CLEAN GLOVES inside the GARBAGE BAG, dedicated BEDPAN, bring soaker pad extra paper (verbalized the dedicated template for v/s sheet & GLASGOW COMA SCALE) and dedicated pen, dedicated PENLIGHT, cylinder measurement, BLUE GARBAGE bin, dedicated stethoscope and BP machine, MAKE SURE theres A CLOCK, garbage bag, tape, temperature and O2 stat, blue pad [make sure to wear gown and gloves CONTACT PRECAUTION] 3.) INTRODUCE SELF AND GLANCE PATIENT POSITIONING; SHOULD BE Supine or 10 to 15 deg. AS LONG AS Hes NOT ON HIGH FOWLERS d/t Increase ICP, Safety (bed brakes, appropriate bed height, call bell within reach no obstruction) QUICKLY CHECK IF O2 are working, IV, and other devices --- PRIVACY 4.) Do a head to toe asmt (follow guidelines) Focus asmts: PAIN- PQRST, ASSESS LOC, ANY NAUSEA, VOMITING, from Increase ICP? GLASGOW COMA SCALE, ABD wound with MRSA asmts (make sure its well approximated) ASSESS SKIN for MRSA S&S such as boils, cellulitis etc. MAKE SURE TO TAKE BP NOT on THE AFFECTED SIDE.

5.) Teach patient to D B and Coughing (splint pillow). Make sure patient wiggle/move his toes and reposition himself q2h. Teach about the catheter care. Press call bell if pt. feels nauseated, encourage the patient to maintain 10- 15 deg. To decrease ICP 6.) ASSIST her to BED PAN with soaker pad 7.) administer medication (Plavix) OPTIONAL if not done in the begin. 8.) SAFETY AGAIN