Week 13: Case Scenario

Scenario 1
The nurse is missing the patient’s background information: vital signs, labs, allergies/reactions,
precautions. She also did not include any past medical history or surgeries the patient has had.
She did not include assessments done on the patient, whether the patient had any dressing change
or was on oxygen therapy, whether the patient had an IV line or a feeding tube in, if the patient
had any bowel movement since he was admitted. She also did not have a plan of care for the
patient.
Scenario 2
Patient had Foley catheter inserted at 10:15am (16Fr, balloon inflated with 10mL sterile water)
because no voiding in 8 hours. Catheter inserted in one attempt, voided 250mL clear, yellow
urine and tolerated the procedure well; patient reported no pain. Tubing attached to inner right
thigh with bag hung by right side of bed (300mL urine inside). Patient is resting. Delegated
perineal care to Cathy to be done every 8 hours. -----------------------------Mercy Olowoyo, STN.
Scenario 3
Situation: Charlie Knight, 68-yr old male admitted from ER last night for shortness of breath for
the past 3 days. Allergic to peanuts and penicillin., Breathing treatments with incentive
spirometer every hour, Albuterol inhaler every 6 hrs. (last treatment 2 hrs. ago). HR 70, BP
150/79, SpO2 91-92%, weight 88kg.
Background: Hx of COPD, diabetes and hypertension.
Assessment: AxO x3, PERRLA, pt. is ambulatory, diminished lung sounds, bowel sounds in all
4 quadrants, productive cough. Voided 600mL urine, clear yellow color. 18-guage IV in left
lower arm, saline-locked. Very poor appetite but ate half of his breakfast this morning. Chest x-
ray shows infiltrates in left lower lobe. 2L O2. Wheezing sounds present all over.
Recommendation: Put in an order/request for a nebulizer for the patient.