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Asked by ProfHeatMonkey101

Patient Introduction

Location: Hospital surgical floor  

Time: 07:00

Handoff report from the nurse leaving the shift:

Situation: Linda Waterfall is a 48-year-old patient of Dr. Samuels. She is scheduled for a left mastectomy this morning at around 08:30.   

Background: Linda is a Native American woman who was diagnosed with an aggressive form of breast cancer after a biopsy just a few days ago. She told me that her family lives far away and that they wanted her to come home to meet with the tribal healers before scheduling the surgery. She did not do that and instead took the first available date for the surgery. She’s been a little nervous, and while getting checked in, she mentioned that she has not been sleeping well. She shared that her mother died of complications of surgery. She also said she’s worried about the cancer and very unhappy about losing her breast. Her cousin, Alice, brought her to the hospital this morning and is staying with her until she has to go into surgery. 

Assessment: I’ve checked her in, and she is settled in room 2046. Now we’re just waiting on the call from surgery (Dr. Samuels). Her consent forms are signed and on the chart. I started her on intravenous (IV) dextrose 5% lactated Ringer’s. It’s infusing at 80 mL/h through an 18-gauge catheter in her right forearm. Her vital signs at check-in were as follows: heart rate, 80 beats/min; respiratory rate, 18 breaths/min; blood pressure, 135/85 mmHg; and temperature, 37.2°C (99.0°F). She has a small incision on the left breast from a biopsy last week. Her stitches were removed yesterday. The incision is dry and uncovered. She’s able to get to the toilet without assistance, and she will receive a urinary catheter in surgery. She reports she has had nothing by mouth since before midnight. She takes no regular medications at this time and refused to take her preoperative lorazepam.

Recommendation: As I mentioned, she seems pretty nervous, so I recommend checking in on her and introducing yourself. I told her I would be leaving at 07:00, so she should be expecting someone new.

Feedback Log

  0:00 Patient
  0:00 You checked scene safety. It was correct to check scene safety in order to maintain your own safety.
  0:06 You introduced yourself.
  0:40 You washed your hands.
  0:56 You identified the patient.
  1:16 You asked if the patient had any known allergies.
  1:29 You performed medication reconciliation.
  2:04 You asked the patient: Is it OK for your cousin to be here, while we talk? It was correct to let the patient give her consent for letting her cousin be a part of the interview.
  2:20 The patient said: Alice! Don’t leave me! Nurse, she said she wanted some coffee.\nYou answered: Mrs. Waterfall, I will stay with you if Alice wants to get some coffee. \nYou used the therapeutic technique of offering self.
  2:37 You assessed the respiration.
  2:59 You checked the pulse oximetry.
  3:18 You checked the radial pulse.
  3:32 You measured the blood pressure.
  3:48 You measured the temperature.
  4:07 You auscultated the lung sounds.
  4:22 You auscultated the heart sounds.
  5:03 You checked the patient’s skin.
  6:15 You asked the patient: I would like to ask you a series of questions about how you are feeling to help me better understand how together we can start to plan your care. These are questions I ask all of the patients I see. May I ask you these questions?
  6:44 The patient said: All of this talking, it’s just a waste of time.\nYou answered: Do you feel that no one understands your feelings? \nYou used the therapeutic technique of verbalizing the implied.
  10:38 You supported the patient about religous beliefs.
  10:44 You supported the patient about treatment.
  10:55 You supported the patient about medicine bundle.
  11:11 You supported the patient about family far away.
  11:37 You supported the patient in taking deep breaths.
  11:49 You supported the patient’s cousin about family relations.
  12:49 You asked the patient: Can you tell me a little bit more about what’s going on with you today? It was appropriate to ask the patient what was going on with her to get an understanding of this.
  13:12 The patient said: I had a horrible morning! I could not find my bag, then I broke a glass, and I could not get in touch with my father. My life is falling apart!\nYou answered: You must be feeling as if everything is out of your control. \nYou used the therapeutic technique of translating to feelings.
  13:29 You asked the patient: Over the past year, when did you feel your best? It was appropriate to ask the patient about when she felt her best.
  13:47 The patient said: You are trying to kill me by making me go through this surgery without it. All of you are out to get me. You want me to die!\nYou answered: Ms. Waterfall, I am your nurse and I’m here to help you. \nYou used the therapeutic technique of giving information.
  13:53 You asked the patient: Do you have any difficulty with your breathing? The patient said: Yes. I feel I can’t breathe.
  14:21 You asked the patient: Do you have chest pain? The patient said: No, I don’t have chest pain.
  14:53 You asked the patient: Do you have energy to do the normal activities necessary to get through the day? The patient said: Yes, I have no trouble with energy once I get up in the morning.
  15:04 You asked the patient: Tell me about any changes you have had in your sleep over the past few weeks? The patient said: When I am anxious I have a hard time sleeping. Recently this has been the case.
  16:49 You asked the patient: Tell me about any changes you have had in your sleep over the past few weeks? The patient said: When I am anxious I have a hard time sleeping. Recently this has been the case.
  17:04 You asked the patient: Approximately how many hours of sleep do you get each night? The patient said: I sleep about 7 hours a night.
  17:15 You asked the patient: Have you lost or gained weight over the past month? The patient said: No, I am about the same weight.
  17:36 You asked the patient: Have you had any changes in your appetite over the past month? The patient said: My appetite has been about the same.
  17:49 You assessed the patient’s IV.
  18:24 You observed the appearance.
  18:30 You assessed the attention.
  18:37 You observed the motor activity.
  18:44 You assessed the speech.
  18:49 You assessed the thought processes.
  19:21 You asked the patient: Can you tell me where we are? The patient said: Yes, I am in the hospital, but I don’t know if I want to stay. I can’t have the surgery without my medicine bundle to protect me. It is very important to me.
  20:41 You asked the patient: Do you have any thoughts or wishes to harm or kill yourself? The patient said: No.
  20:55 You asked the patient: Have you ever tried to harm or kill yourself? The patient said: No.
  21:09 You asked the patient: Can you tell me what a desired outcome of treatment would be for you?
  21:21 The patient said: Do you think I should have this surgery?\nYou answered: Do you think you should? \nYou used the therapeutic technique of giving reflection. This response encourages the patient to make decisions independently.
  21:31 You asked the patient: Are you frightened of anything?
  21:42 The patient said: I’m not sure what to do.\nYou answered: Go on. \nYou used the therapeutic technique of offering general leads.
  22:51 You supported the patient in taking deep breaths.
    You should have educated about possibilities and advocating for the patient.
  23:18 You asked the patient: Are you frightened of anything? The patient said: When I have a panic attack, I am frightened I will die.
  23:30 You educated about discharge plans. You should do this after contacting the provider.
  23:51 You educated about possibilities and advocated for the patient.
  24:39 You called the provider. You should have contacted the provider before educating about discharge.
  24:58 You washed your hands.
    Generally, anxiety is divided into four levels:lt;/p>lt;p>lt;ul>lt;li>Mild: Mild anxiety may increase the person’s sensory perceptions. The person is alert and can see, hear, and understand what is happening around him or her.lt;/li>lt;li>Moderate: Perception is narrowed. The person may benefit from the guidance of others. The person may experience difficulty concentrating, a change in voice pitch or volume, or trembling.lt;/li>lt;li>Severe: The person may be unable to attend to events even when they are pointed out by others. Generally, the person experiences distorted perceptions, a sense of impending doom, a rapid heart rate, and rapid breathing.lt;/li>lt;li>Panic: The person may be unable to focus, want to flee, feel paralyzed by fear, or be completely withdrawn or extremely agitated.lt;/li>lt;/ul>lt;/p>lt;p>De-escalation techniques for patients with anxiety include the following: speaking while positioned directly in the patient’s field of vision; sitting down and asking the patient to sit down; giving the patient concrete directions; and keeping a clear, calm voice. As the patient calms, breathing exercises may be used.lt;/p>lt;p>It is important to be able to distinguish between an anxiety attack and a heart attack. Physiologic concerns should always be initially ruled out, as symptoms of panic and a heart attack are often indistinguishable.lt;/p>lt;p>Although it is important to never assume that an individual has a certain belief system based on his or her culture, assessing a patient’s spiritual beliefs is vital. This case illustrates how greatly a person’s spiritual beliefs can influence his or her health outcomes.lt;/p>
    You got 92%

1- After reading the case please write a Soap Notes for the patient

2-Write SBAR

3- write a Care Plan (at least 2) Assessment, Diagnosis, Outcome/Planning, Intervention and Evaluation.

SCIENCE
HEALTH SCIENCE
NURSING
NUR 3262L

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