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A night in the life of an rn

A Night in the Life of an RN; Exhibiting the ANA Scope and Standards of Practice

Group Activity

  1. Read the following scenario. Identify the passages that illustrate each Standard of Practice, by highlighting them in the corresponding colors.

Standards of Practice:

Standard 1. Assessment

Standard 2. Diagnosis

Standard 3. Outcomes Identification

Standard 4. Planning

Standard 5. Implementation

  • Standard 5A. Coordination of Care
  • Standard 5B. Health Teaching and Health Promotion

 Standard 6. Evaluation

Nurse=John

Patient=Mike Boylan

Unit=Adult Critical Care

John is a registered nurse (RN). He earned his ASN 15 years ago and went back to school and graduated with his BSN 5 years ago. John, a nurse, has worked on this Adult Critical Care (ACC) unit for the last 5 years. He has begun to explore the possibility of going to graduate school to pursue a career as Clinical Nurse Specialist (CNS) on the same ACC unit. He is an active member on the clinical practice committee both for his unit, and as representative for his unit on the hospital wide clinical practice committee. These committees focus on developing Clinical Practice Guidelines that reflect the latest Evidence-Based Practice and lead to improved quality as evidenced by improved outcomes and patient safety.

 This evening, he has come in to work an hour before his shift starts to attend an in service about how vigilant oral care can help prevent ventilator associated pneumonia.

He enters the breakroom at 6:45, writes down his assignment for the day. He has two patients assigned to him. One patient, Louise McGrigg, is relatively stable and the hope is for her to be transferred to the medical surgical unit tomorrow. The other patient, Mike Boylan, is currently stable, but concerning, in that he is 77 years old and has many co-morbidities and was in a motor vehicle accident 1 day ago. After writing down his assignment, he says hello to Jack, a new graduate nurse that started on the unit a month ago. He notes the concerned look on Jack’s face and asks him if everything is okay. Jack responds that he is just a little apprehensive because his assignment is to take care of two patients that are both on a ventilator and he feels unsure if he is ready for the assignment. John indicates his understanding and tells Jack that he will help to manage the patients by being a resource for him throughout the night. He suggests that Jack gets report then finds Jack so he can help Jack organize and prioritize the patients’ needs. Jack looks relieved. John leaves the breakroom to find the day shift nurses so they can complete bedside report.

John receives report on Ms. McGrigg. He is familiar with her as has taken care of her several times during her stay. The dayshift nurse will continue to care for her until John has received report on his other patient and is ready to assume care of both of patients.

With the off-going day shift nurse, John enters Mr. Boylan’s room for bedside report.

Report:

I

Introduction

The day nurse introduces John to Mr. Boylan and lets the patient know that John is an excellent nurse with many years of experience. She tells Mr. Boylan that they would like to do report at the bedside so he can be a part of the report and they can work together to make sure everything is passed on correctly to ensure safe care.

P

Patient

Mike Boylan, 77-year-old male, Date of Birth : 9/6/1938, Room# ACC4. Together they compare the information to his identification band.

A

Assessment

Mr. Boylan has been having pain and some difficulty breathing today. His vital signs, T 99, P 116, RR 24, T 99, B/P 103/65, oxygen saturation 90%. Mr. Boylan is on a monitor to continuously monitor his vital signs. Chest tube is draining bright red fluid from his right side at a rate of 30 ml/hr. He is receiving oxygen via nasal cannula at 3 liters. He is receiving dextrose/normal saline running at 75 ml/hr. He has a large skin tear on his left forearm, a small amount of light pink drainage is noted on the dressing. Mr. Boylan has been awake and responding appropriately. (This is evidenced when he makes a quick sarcastic joke for the two nurses)

S

Situation

Before entering the room, the nurse relays Mr. Boylan was admitted yesterday evening. He was in a motor vehicle accident (MVA). He was brought into the ER with 4 broken ribs on the right and 2 on the left. His right lung was collapsed. He appeared slightly confused, repeating the same questions verbatim. He did recognize his three step children when they entered the trauma room. Prior to having the chest tube inserted, he could be heard saying, “Please let me die, just let me die.” One of the stepdaughters explained that he had had chest tubes before and knew how uncomfortable they are. He is a full code. He has no known allergies (NKA). His condition is guarded considering his co-morbidities and we are watching his heart rate and blood pressure closely. His heart rate has been elevated and the rhythm has been mostly A Fib. He has been taking Fentanyl intravenously for pain and the last dose was 45 minutes ago, but each time he receives Fentanyl his B/P decreases to a systolic less than 100.

S

Safety Concerns

He is on bedrest, because he is a fall risk with the chest tubes, intravenous fluids tubing, and narcotic pain medication, and his unstable heart rate and blood pressure. The bed alarms are set and he has been told the importance of staying in bed and using his call light,that is in reach, to call out for help, if he needs anything.

His heart rate is AFib and his blood pressure has been dropping, oxygen saturation is 90%.

THE

   

B

Background

Comorbidities: Upper left lobe of lung removed many years prior to this accident, Chronic Obstructive Pulmonary Disease (COPD), on daily nasal cannula oxygen of 1-2 liters, Congestive Heart Failure (CHF), new diagnosis of Parkinson disease. Previous Medical/Surgical History: Rheumatic Fever as a child resulted in heart valve failure, A Fib, History of Open Heart Surgery 15 years prior to replace the valve and a failed attempt to correct AFib. Multiple stents placed to correct coronary artery disease. Left upper lobectomy as result of a biopsy revealing a benign tumor, history of mesothelioma discovered. Smoked for 30 plus years, quit 20 plus years ago. He has a history of Guillian-Barre syndrome x2, both brought on after surgery or infection.

Current Medications: Medications to treat elevated cholesterol, Coumadin (blood thinner to decrease risk of stroke due to AFib), albuterol inhaler as needed, Lasix a diuretic to manage the CHF, nitroglycerin as needed for chest pain.

Family History: Brother and Sister died of Cancer (Colon and Brain, respectively).

A

Action

The resident recently ordered Vicodin by mouth to be given every 4-6 hours for pain and discontinued the Fentanyl order. The resident also put in a new order for Digoxin to treat the A fib and his lowered B/P.

Dressing changes are twice a day and currently due.

T

Timing

Monitor closely. Our goal is to prevent the need for assisted ventilation.

O

Ownership

The trauma team is the primary provider, cardiology, and respiratory is consulting.

N

Next

Give new medications ordered.

Continue to monitor his vital signs, heart rhythm, respiratory status, chest tube drainage, and sign and symptoms of infection closely. 

Once report is received, John quickly looks at Mr. Boylan’s history, he is already familiar with Ms. McGrigg. He looks at both charts for new orders and develops a strategic plan to organize the care he will provide for both patients tonight. John determines the care that can be delegated to the certified nurse’s aide (CNA) that has been assigned to his patients tonight. He knows the CNA and has worked with her for the last 5 years, so he is confident in her abilities and delegates the care responsibilities appropriately. He lists the tasks he would like her help with and negotiates a plan that makes the best use of their individual skills and time. The CNA repeats back the plan to alleviate any confusion that might lead to errors.

He meets with Jack, who already has a good plan started and offers him reassurance. Jack seems more comfortable with the assignment now.

He is then ready to see both of his patients. He begins with Ms. McGrigg, because she has medications due and has less intensive needs and he knows that once he takes care of her current needs, she will likely be able to get some rest and he will be able to focus on the close monitoring required for Mr. Boylan as he makes the medication changes.

He enters Mr. Boylan’s room at 8:15pm. He proceeds to collect more data from him, initiating a conversation to learn more about how he is feeling, symptoms he might be experiencing and anything that might feel different. He is sure to use good therapeutic communication techniques to achieve effective communication and gather all the necessary, pertinent data needed to provide safe, quality care for Mr. Boylan. He verifies information about his background and asks questions about his family and his support system. He uncovers that Mr. Boylan has many health problems and hospitalizations in the last 10-15 years.

He has also been acting as the primary care giver for his wife, who struggles with chronic pain and mobility issues, as well as depression. His wife is currently in a rehab facility after just being transferred from the hospital the night of his MVA. She had been hospitalized with Noro virus and had a Heart attack and stroke while hospitalized for 2 weeks. She had been in ICU herself on a ventilator and was just now recovered enough to go to the rehabilitation center. He is very worried about her and feels very bad about the accident. He shares that he attempted to make a left turn into a busy street, an act that his wife had repeatedly warned him against the many times they come upon it in the past. He has three step children that he is very close too and that are taking care of both him and their mother. He is concerned about his and his wife’s future as he and the children had already begun to discuss he and his wife moving to an assisted care living situation because of his recent Parkinson’s diagnosis. He says he is reluctant to take this step, but realizes it is the smart thing to do.

After talking with and performing a physical assessment that is unchanged from the report he received, John determines the priority nursing issues for Mr. Boylan are, physically, 1. Ineffective airway clearance, related to difficulty taking deep breaths, patient position: bedrest. 2. Decreased cardiac output related to irregular rhythm and increased work of heart. Psychosocially, Anxiety related to situational crisis: uncertain health status, concern for his wife’s health status and separation from her, uncertainty of the future.

John sets goals with Mr. Boylan to:

  1. Maximize his airway clearance and cardiac output during his shift.
  2. Decrease in his anxiety level by the end of John’s shift.

John develops the following interventions:

To treat Mr. Boylan’s difficulty breathing:

  1. Give prescribed pain medications: Rationale: Decrease rib pain, so that he can take deeper breaths.
  2. Frequently change positions to promote the movement of secretions. Place him a semi or high fowler’s position with legs down. Rationale: Elevating the head of the bed and legs down may decrease the work of breathing and decrease the work of the heart.
  3. Coordinate respiratory treatments and physical therapy treatments with peak pain control. Rationale: Patient is able to more effectively complete tasks that will promote airway clearance.
  4. Provide frequent sips. Rationale: Thins secretions.

To treat irregular rhythm and increased work of heart:

  1. Give new cardiac medication to help treat Afib Rationale: promote a more effective rhythm.
  2. Monitor for symptoms of CHF and decreased cardiac output: Rationale: Make physician’s aware of any change in status so treatment plan may be altered.
  3. Give new pain medication regimen: Rationale: By mouth Vicodin will not decrease the blood pressure as much as IV Fentanyl.
  4. Provide a restful environment. Rationale: Rest helps lower atrial blood pressure and reduce the workload of the heart.

To treat uncertainties that his current health and future for he and his wife and relieve the worry of separation:

  1. Use empathy to encourage Mr. Boylan to interpret the anxiety symptoms as normal. Rationale: Providing psychological support can reduce the symptoms and problems of anxiety.
  2. Collaborate with Social Work to provide coordination of services for Mr. Boylan and his wife. Rationale: Addresses his legitimate concerns.
  3. Set up a phone call or facetime between Mr. Boylan and his wife. Rationale: He can see her needs are being taken care of.
  4. Educate him on all activities, procedures in a way he can easily understand. Rationale: Promotes a therapeutic relationship between nurse and client, by developing trust and alleviating the fear of the unknown.

John carries out this plan throughout his shift and documents all assessments data, interventions, the nursing plan of care developed, and the evaluation, as well as the recommended plan moving forward. As the shift comes to an end and he prepares for report, he looks back at each of his interventions and notes that they were all completed, he then looks at his goals and determines if they were met or met or not. He talks with Mr. Boylan and determines that the goals of maximizing his airway clearance and cardiac output during his shift and decreasing his anxiety level by the end of John’s shift were met, they agree there is no revision needed, but that the goals should remain for the next shift.

Before he says goodbye to Mr. Boylan, John remembers that the day shift nurse had relayed the story of when Mr. Boylan came into the ER and said to his stepchildren, “Please let me die…” He thinks that it was probably just said in the stress of the moment, but feels it is his duty to talk with Mr. Boylan about it and determine his healthcare wishes, if his situation were to worsen. He explains to Mr. Boylan that it is a real possibility that he might need ventilator assistance with breathing, that with his cardiac and respiratory challenges, he might get worse before he gets better. He explains that once on the ventilator the chance that he will not be able to come off of it and successful breath on his own exists as does the chance that he would be on the ventilator for a short time as he heals then be weaned off and take over on his own. He explains that should that happen and even if it doesn’t, he will likely have an extended stay in a rehabilitation facility. He also reminds him that the social worker had already started to look into making sure that he and his wife were in the same facility. John shared this information with both Mr. Boylan and His stepdaughter who came to visit during the shift. He gave them time together to discuss everything and called the chaplain to help Mr. Boylan fill out an Advanced Directive so that his healthcare wishes would be known and followed.

John fills out a standardized written report sheet for the next nurse as one way to ensure good communication through the transition of care.

After giving report, he realizes that his shift is not quite over, because he needs to meet with the director of the unit to go over his annual Performance Evaluation and discuss how he is doing meeting the scopes and standards of his nursing practice. They will also discuss his goals for the future, ways he can improve and continue to grow in the nursing profession. After this is complete, he heads home for some much needed rest.

Provide examples from the scenario that illustrate competency in:

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