NUR435 Final SIM

Question 1

Report

Answer 1

this patient has been DIRECTLY ADMITTED to the Med Surg unit by the PCP for observation due to reports of EPIGASTRIC/CHEST discomfort occurring with increasing frequency over the PAST 2 WEEKS
- BP NORMAL
- P NORMAL
- SpO2 NORMAL
- Temp NORMAL
- GCS NORMAL
- A/O NORMAL
- Pain 0/10 at rest 8/10 with symptoms

Question 2

4 things to do upon entering the room and talking with the patietn

Answer 2

Introduce self and role (THE NURSE)
Perform hand hygiene upon entering the room
Use 2 patient identifiers (verbal against wristband)
Clarify reason for admission

Unplug the wow lol

Question 3

physical assessment (pre chest pain)

Answer 3

Vital signs - place SpO2 onto the finger and cycle the blood pressure

Heart - APEToMan (Aortic, pulmonic, erbs, tricuspid, mitral)

Lungs - 3 place anterior and posterior
SCOPE TO SKIN DO NOT BLOCK STETHOSCOPE VIEW

Radial pulses bilaterally
Peripheral pulses bilaterally - DP

Peripheral edema

Question 4

pain assessment (pre chest pain)

Answer 4

OLDCART
Onset (“how long ago did the pain start”)
Location
Duration (“How long does the pain last when experienced”)
Characteristics (“What is the rating” “What does it feel like”)
Aggrevating factors (Makes it worse
Relieving factors (Makes it better)
Treatment
- what did you do for this issue? did you go to the doctor? any over the counter meds?

Question 5

During chest pain cardiac assessment

Answer 5

Assess VS - cycle BP

Question 6

during chest pain lung assessment

Answer 6

ASK - Any difficulty breathing
HOB up
activate standing orders for 2L NC

Question 7

during chest pain
- GI
- Skin
- Neuro

Answer 7

Are you feeling nauseated
Do you feel anxious or restless

Feel skin with backs of hands

Question 8

during chest pain pain reassessment

Answer 8

ask on a scale for 1 - 10
the location of the pain

Question 9

Medication administration

Answer 9

Wheel wow to bedside and ask patient to state name DOB and compare with WOW, ask for any allergies

pull the 0.4mg nitro SL 3 times every 5 minutes for chest pain and read down when pulling the med out

compare the medication with the WOW and state 0.4mg nitro SL 3 times every 5 minutes for chest pain

Scan the patients wrist band and medication and state 0.4mg nitro SL 3 times every 5 minutes for chest pain

explain why this medication is being given and some side effects: Alright Kris, this medication is going to dilate your arteries around the heart helping with blood flow and should improve the pain, this medication is going to go under your tongue and you may feel some tingling. You may also feel some mild headaches and some dizziness. You should start to feel some relief in 1-5 mins and if not, I will reassess your pain and if not any better I can give you another dose in 5 mins. I am going to call your doctor in the meantime

Question 10

ISBAR

Answer 10

Hi my name is Lani and I am the nurse with 2203-D are you familiar with this patient? This is Kris Donnavan, a ## year old ________ full code. Currently Kris is complaining of some chest pain. Prechest pain vitals are BP, HR, SPO2 now the vital signs are BP, HR, SPO2 with a chest pain of 10/10. The patient is a direct admit from the PCP due to reports of EPIGASTRIC/CHEST discomfort occurring with increasing frequency over the PAST 2 WEEKS. My assessment is the lung sounds are clear and S1 and S2 heard. I placed Kris on 2L NC and gave one dose of nitro at ___ time. On the monitor the heart rate looks irregular. I am concerned the patient is experiencing an acute MI. I would suggest getting a STAT EKG and labs for cardiac enzymes. are there any recommendations?

**place him on 4L NC

“Just to clarify you would like 4L NC?”