After you have reviewed Lucy’s chart and

After you have reviewed Lucy’s chart and listened to her monologue, use the clinical judgment model described in Module 2 to review Lucy’s current clinical condition. initial assessment of Lucy’s situation, using all sources of information. Recognize and analyze the important cues. Your response should include (but is not limited to) What are Lucy’s strengths? What are your concerns for Lucy? What is the cause of your concern? What additional information do you need What are the priority concerns for Lucy? Prioritize hypothesis (i.e. urgent, likelihood, risk, difficulty, time, etc.) Generate solutions: Consider multiple interventions that can impact goals Consider what are your options as the RN who is planning Lucy’s care? What referrals would you recommend to Lucy and the health care provider? Record a response that you could share with Lucy. In your response describe your concerns and options for her care. Take action. (Implement solutions to address highest priority) For this discussion, similar to Module 1, you will upload a video recording in Canvas, and address the four parts of the assignment listed above. The recording will be a response that you, the RN caring for Lucy, are sharing with the charge nurse. You will also record an SBAR (situation – background – assessment – recommendations) with recommendations to the RN, who will be taking over of Lucy on the oncoming shift. PATIENT CHART Chart for Lucy Grey SBAR Report from paramedic Time: 12:30 PM Person providing report: Paramedic who brought Lucy to the ED Situation: This patient called 911 after having a dizzy spell and a fall in her home. When we arrived, she was sitting on her couch in her living room, alert and oriented. Background: Lucy Grey lives alone, lost her partner to cancer a few months ago. She has had several episodes of falling during the past 3 months. She has been transported to the ED but not admitted in the past. Assessment: Her blood pressure is 160/88, heart rate is 102, respirations 20, and her oxygen saturation has been in the 90’s. She is currently on 2 liters of oxygen per nasal cannula. She was apologetic for calling us, said she was scared about falling but didn’t think she was seriously hurt. Patient denies taking any medications today, states she takes celecoxib 200mg in the evenings. States she had tea and oatmeal for breakfast. No complaints of pain, currently. She has good mobility, a little slow at times due to “stiff knees.” There is a mild abrasion on her arm, we just taped a gauze pad on it. We inserted a saline lock in her right forearm. Recommendation: Assess and follow up on recurring falls. Chart Materials Lucy Grey – Simulation 3 2 Nursing Notes Date/Time: Patient was brought to ER by ambulance after a fall at home. She is alert, oriented and in no acute distress. Has a scrape on left arm; saline lock in right forearm. States she has been seen over the past few months in this emergency room for falls. Medical record requested. Allergies/Sensitivities: None known Admission Assessment Brief Description of Client Name: Lucy Grey Date of Birth: 05/24/19xx Gender: F Age: 74 Weight: 110 lbs. (50 kg) Height: 64 inches Race: (Faculty can select) Religion: (Faculty can select) Patient Name: Lucy Grey MRN: Room: Doctor Name: Barbara Green, MD DOB: 05/24/19xx Date Admitted: Age: 74 Chart Materials Lucy Grey – Simulation 3 3 Major Support: Support Phone: 555-1210 Allergies: no known allergies Immunizations: Influenza vaccine, yearly Attending Physician/Team: Barbara Green, MD Past Medical History: Osteoarthritis; right knee replacement at age 65. On celecoxib 200 mg po daily History of Present Illness: History of falls in her home. Patient has called 911 three times, about once a month since the death of her partner three months ago. Had comprehensive neurological work-up done at her last admission, three weeks ago. No physiological abnormalities were noted at that time. Social History: Single, lives alone, partner Julia Morales died 3 months ago. Retired teacher. Primary Medical Diagnosis: History of falls with reported fall at home today Surgeries/Procedures & Dates: Right total knee replacement at age 65 Lucy Grey Monologue Script This monologue takes place a few months after Julia’s death. Lucy is in the emergency room. Well, here I am again, waiting to be seen by the emergency room doctor. This must be the third time this has happened since Julia died. I miss her so much. I never knew it would be so lonely in that house by myself. Nora comes to visit every once and awhile. In fact she’s on her way here now, with my neighbor Adele. I don’t want to scare them though I know Adele saw the ambulance and must be worried. This has happened about once a month I think. I feel okay, then for no reason at all I just get anxious and dizzy. My heart kind of pounds and I just feel like I can’t walk or do anything. One time I fell, but I didn’t get hurt too bad. This time I almost fell, landed on my couch and scraped my arm. I think I tripped over my shoe that I was going to put on. I was able to reach for the phone and call 911. I felt a little better by the time the paramedics got there, but they thought I should come in and be checked out anyway. I need someone to look at this scrape on my arm. They should probably check my knees too. They’re a little weak. I had surgery on one of them. Most days I’m fine, it’s just once in a while……. I don’t think we ever had to call 911 when Julia was alive. I don’t remember ever having these dizzy spells then. My knees were weak, but I took it easy and never fell that I can recall. I was feeling pretty bad these past few years that I couldn’t walk as far or as fast as we used to. We loved to travel, and hike around new places. We traveled all over. I think my favorite place was Ireland. Julia wanted to go there, she picked that trip. It was wonderful. We rented a car and just drove all everywhere. We went out to pubs for music every night, and we went to the Waterford crystal factory. It was lovely. It’s so sad to know we’ll never have those experiences again. Oh, we loved our adventures! They are all over now. It’s just me in that old house. Nora visits when she can, every few weeks or so. Neil came once for my birthday. That was nice. My neighbor Adele stops by, but not very often because she has her grandkids to take care of. Sometimes days go by and I never talk to another soul. That never happened when Julia was alive. She always had something to say! I felt safer then. I never had these dizzy spells. Maybe the doctors will figure it out this time. SCIENCE HEALTH SCIENCE NURSING NUR 104

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