NUR 259: Ticket to ClinSim Day 3

In preparation for your ClinSim day, be sure to complete the following PRIOR to the scheduled day:

REQUIRED PREP WORK:

  • Required reading to complete your ticket to ClinSim.
  • Medical-Surgical Nursing Textbook (Lewis), 10th ed.Osteoarthritis, Chapter 64 (pgs. 1517 – 1524).Rheumatoid Arthritis, Chapter 64 (pgs. 1525 – 1532).Addison’s Disease, Chapter 49 (pgs. 1178 – 1180).Acid-Base Imbalances, Chapter 16 (pgs. 286 – 291).Chronic illness and Older Adults, Chapter 16 (pgs. 63 – 74).Poisonings, Chapter 68 (pgs. 1642 – 1644).Laboratory Reference Intervals, Appendix C (pgs. 1655 – 1662).
  • To review how to compose an SBAR report watch the following videos.
  • Watch the following SBAR video to see an example of a thorough SBAR (1 min 10 secs).

Click on the link below. https://www.ahrq.gov/teamstepps/longtermcare/video/13sbar_ltc/index.html

  • Download the “Ticket to ClinSim Day 3” document and complete the assignment.  
  • Upload your completed “Ticket to ClinSim Day 3” to canvas PRIOR to Tuesday, 5/18, no later than 5:00 PM.  
  • Submit as DOC, DOCX or PDF document only. Any other files including (JPEGs) will not be accepted—the student will not be able to join the simulation activity for the day and a zero will be submitted in the grade book. 
  • If you mistakenly submit a blank copy of the assigned homework, be sure to upload the document you intended to submit again. Canvas is set to accept multiple upload attempts.
  • Print a hard copy of your completed “Ticket to ClinSim Day 3” to have your answers with you.
  • Expect to be called upon (at random) to participate in discussions and activities during our virtual meeting.
  • Plan to attend the virtual simulation day on 5/19/21 from 9:30 AM – 12:30 PM via TEAMS.

An invite to the meeting will be sent via Teams by your assigned clinical facultybe sure to accept the invite to be able to join your assigned group meeting.

Should you have any questions, do not hesitate to contact Prof Quiroz at bquiroz@carrington.edu or via phone, 208-724-3401.

NUR 259: Ticket to Clin Sim Day 3

Student Name:  Harmandeep Jassal                                                                                      

Instructions: In this evolving case study, you will need to read EVERY component and information presented in the “Case Study Progression” to answer the questions to the best of your ability.

Be sure to utilize your med surg and Saunders textbooks along with your drug and lab eBooks to look for content not yet covered. If using the internet, be sure you draw information from reliable sources.

Client Information:

Rose Nylund is an 83-year-old female who lives with her cat, Sam, in a senior apartment. She suffers from rheumatoid and osteoarthritis, cataracts, and Addison’s disease (adrenal insufficiency). She no longer drives but takes the bus to the market three times a week for groceries. Her church is at the end of the block, and she never misses a Sunday service. The home health nurse comes to see Rose once a week since she came home from the skilled care rehabilitation facility three weeks ago after fracturing her hip. Her physical therapist also comes to her home twice a week. Her rehabilitation is going well, and she’s independent with the use of a walker when she is outside of the house. Rose’s daughter and son live out of the state but stayed with her the first week after she returned home.

During the visit, the home health nurse reviews Rose’s medication bottles, which read:

  • Prednisone, 5mg tablets
  • Furosemide, 20mg tablets
  • ASA/Oxycodone, Hydrochloride tabs
  • Aspirin, Extra Strength
  1. Determine the specifics of each of Rose’s medications. For each shaded box in the table below, select the correct answer by highlighting the answer(s) in yellow.
MedicationDose, Route, FrequencyDrug ClassPatient Teaching
Prednisone5 mg PO daily1. Mineralocorticoid 2. Glucocorticoid 3. Loop diuretic 4. Osmotic diureticIncrease dose during times of stress.
Furosemide20 mg PO dailyDiureticSelect all that apply 1. Report signs of infection. 2. Monitor potassium levels. 3. Weigh self, daily. 4. Increase oral fluid intake.
ASA and Oxycodone Hydrochloride1 to 2 tablets every 4-6 hours for pain as neededSelect all the apply Non-steroidal anti-inflammatoryNarcoticAnalgesicAntiplateletSurgical site pain
Aspirin Extra- Strength325 mg PO  2 tabs every 4 hours   PRN500 mg PO  2 tabs every 6 hours PRN725 mg PO   2 tabs every 4 hours PRN1000 mg 2 tabs every 6 hours PRNAnalgesic, antipyretic, anti-inflammatory, and platelet aggregation inhibitors.Arthritis pain
  • As the home health nurse reviews the medications discussed in the introduction of the case study, what is concerning?                                                           
  • Reflect on the information provided in the introduction of the case study and what the home health nurse has collected to identify at least 3 areas of concern—think ABCs to determine priority.

Case Study Progression: The home health nurse asks Rose about her pain since surgery. Rose says that her pain is worse in the mornings and at bedtime, so she’s been taking extra pain medication and has been sick to her stomach lately.

The home health nurse completes a physical examination and finds that Rose is not aware of the day or time but can identify self and the current president correctly. Her skin is bronze in appearance and the incision on her right hip is almost healed.

Her temperature is 99.4°F (37.4°C), heart rate 98, respirations 26, blood pressure 99/47 lying and 78/40 standing with reported dizziness. When asked for any additional new symptoms, Rose tells the nurse that she has this strange ringing in her ears.

  • Given the assessment findings and the information gathered by the home health nurse (in the case study progression above), identify the top 3 priority concerning issues.
  • What would the home health nurse suspect is/are the reason(s) for Rose’s orthostatic hypotension? (Select all that apply)
    • Furosemide                                                     ☐                
    • Prednisone                                                                       ☐
    • ASA and oxycodone hydrochloride               ☐
    • Adrenal insufficiency                                   ☐
    • Osteoarthritis                                                   ☐
    • Older adult age                                                ☐
  • Multiple Choice Question:

The nurse is concerned about Rose’s confusion, hyperventilation, vomiting, and tinnitus.  These signs and symptoms are consistent with:

  1. Reaction to the pain medication
    1. Dehydration
    1. Acetylsalicylic acid overdose
    1. Poor dietary intake
  • Multiple Choice Question:

The nurse hypothesizes that Rose’s hyperventilation is a result of metabolic acidosis from the acetylsalicylic acid ingestion. What action would be appropriate?

  1. Encourage her to take slow, deep breaths.
    1. Have her breathe into a paper bag.
    1. Moisten her lips and continue to allow the hyperventilation.
    1. Offer her some pain medication.
  2. A call to the health care provider is needed. The nurse prepares an SBAR

(S-situation, B-background, A-assessment, R-recommendation) to communicate the changes in Rose’s condition. Complete each section of the communication form below.

S

B

A

R

Case Study Progression: The home health nurse receives orders to arrange transportation for Rose to go to the nearest emergency department. Upon arrival to the emergency department, the health care provider (HCP) writes these prescriptions:

May 18, 1345 hrs:               

  1. IV D5NS at 50 mL/hr
  2. Methylprednisolone 125 mg IV x 1 dose, now
  3. Glucose monitor reading, now
  4. Complete blood cell count
  5. Metabolic panel
  6. Arterial blood gas, now
  7. Serum salicylate level, now
  • Explain each of the new prescriptions and its purpose (specific to Rose). In other words, why is it being ordered?IV D5NS at 50 mL/hour.
  • Methylprednisolone 125 mg IV x 1 dose, now.
  • Glucose monitor reading, now.
  • Complete blood cell count.
  • Metabolic panel.
  • Arterial blood gas, now.
  • Serum salicylate level, now.

Case Study Progression: Rose’s emergency room nurse receives the following lab report.

Laboratory Report
Labs & DiagnosticsNormalSept 24
pH7.35 – 7.457.28 L
PO280 – 100 mmHg88
PCO235 – 45 mmHg32 L
HCO322 – 26 mEq/liter19 L
SaO295 – 100%97
WBC4,000 – 10,000 μL11.2 H
Hemoglobin12.0 – 17.0 g/dL11.9 L
Hematocrit36.0 – 51.0%39
RBC4.2 – 5.9 cells/L3.9 L
Platelets150,000 – 350,000 μL224,000
Calcium9 – 10.5 g/dL8.9 L
Chloride98 – 106 mEq/L96 L
Magnesium1.5 – 2.4 mEq/L1.9
Phosphorus3.0 – 4.5 mg/dL3.0
Potassium3.5 – 5.0 mEq/L5.3 H
Sodium136 – 145 mEq/L129 L
Glucose70 – 100 mg/dL59 L
BUN8 – 20 mg/dL23 H
Creatinine0.7 – 1.3 mg/dL1.3
Creatine Kinease (CPK)30 – 170 U/L57
Lactic Dehydrogenase (LDH)60 – 100 U/L150 H
Aminotransferase, Aspartate (AST)0 – 35 U/L32
Aminotransferase, Alanine (ALT)0 – 35 U/L42 H
GGT9 – 48 U/L19
Drug Screen
Salicylate Level – therapeutic15 – 30 mg/dL63 H

From the lab report, the nurse confirms that Rose has salicylate toxicity. The HCP orders activated charcoal orally, every 4 hours until the charcoal is eliminated through the stool.  Although the HCP considers alkaline diuresis, it is held because of the hypotension.

  1. Which laboratory finding(s) is/are consistent with salicylate toxicity? (Check all that apply)
    1. Hyperkalemia                  ☐
    1. Metabolic acidosis          ☐
    1. Leukocytosis                    ☐
    1. Hypoglycemia                  ☐
    1. Salicylate level                 ☐
  1. After reviewing the lab results, the health care provider adds an order to Rose’s chart. Activated charcoal orally every 4 hours until the charcoal is eliminated through the stool.

       What is the purpose of the activated charcoal and how does it work? 

Math for Meds:

  1. The nurse is preparing to administer the ordered Methylprednisolone 125 mg IV x 1 dose, now.

       Read the Methylprednisolone label below for the available medication.

NDC 0009-0758 Solu-medrol Methylprednisolone Sodium Succinate
  1. How many milliliters (mL) should the nurse administer? Show your work!

125Mg/125 Mg* 2ML = 2 ml

  • Using the answer, you obtained above, indicate the amount of dose the syringe below will be filled out to.

Case Study Progression: Rose is admitted to the medical surgical unit for monitoring. Over the next 24 hours her condition improves after the administration of the activated charcoal. Her labs results (below) now show the following trends:

Laboratory Report
Arterial Blood GasNormal124523100615
pH7.35 – 7.457.28 L7.32 L7.36
PO280 – 100 mmHg888589
PCO235 – 45 mmHg32 L3640
HCO322 – 26 mEq/L19 L21 L21 L
SaO295 – 100%979697
Drug Screen
Salicylate Level-therapeutic15 – 30 mg/dL63 H43 H20
  1. The nurse interprets the lab result trends (above) as:

Case Study Progression: Rose is preparing for discharge. She is no longer confused and will be discharged to home. The home health nurse will see her daily to confirm she is following the discharge instructions.

  1. Multiple Choice Question:

In preparation for discharge teaching, what should the medical surgical nurse prioritize as a need for Rose?

  1. Complete a medication reconciliation.
    1. Check with the neighbor that her cat is all right.
    1. Have occupational therapy evaluate her ability to go home.
    1. Arrange for her child ren to come and care for her at home.
  1. Multiple Choice Question:

During the nursing assessment of Rose, the nurse enhances communication by doing which of the following?

  1. Interviewing the older adult client with family present to verify responses to questions.
  2. Interviewing the older adult client quickly to conserve the client’s energy.
  3. Restating terms or phrases in different ways if the client does not understand.
  4. Speaking loudly and using many gestures.
  1. In review of acid-base disorders, list common causes for each imbalance.
Respiratory AcidosisRespiratory AlkalosisMetabolic AcidosisMetabolic Alkalosis
    
  1. Arterial Blood Gas (ABG) Review. 

Match the ABG on the left to the imbalance name on the right.

NOTE: You may use the acid base imbalance names more than once; not all options are used.

Answer:ABG ResultsAcid Base Imbalance Name
 pH 7.47, CO2 34, HCO3 261.   Respiratory Alkalosis
 pH 7.46, CO2 40, HCO3 282.   Metabolic Acidosis
 pH 7.32, CO2 36, HCO3 183.   Metabolic Alkalosis
 pH 7.38, CO2 43, HCO3 22Respiratory Acidosis (compensated)
 pH 7.48, CO2 44, HCO3 30Metabolic Acidosis (compensated)
  Normal ABG