Clinical Case Study and Discussion Tool - PATIENT CARE DOCUMENTS

Review the attached instructions in full before starting vSIM to insure that you are prepared for this patient care
exercise.
All 7 (seven) steps forms/charts/questions must be completed prior to your Nursing IV – vSIM Clinical Conference.
Use this template, fill it in or use your own paper/form to write notes for discussion. “Bring” these forms to vSIM discussion
as evidence of preparedness.

STEP 1: Perceptions: Data Collection (assessment):

Complete a Handoff Report Form for each patient you are assigned. You may use any Handoff Report (aka, end of
Shift report or SBARR) document that you are familiar with (or create your own).
Some items that should be included during “hand off” and “data collection”:
Medical diagnosis (initial vs. current)
Pre-existing conditions
Vital signs, Diagnostic tests and Labs (abnormal values and trends)
Procedures/treatments performed or ordered and effect of procedures/treatments on any of the vital signs
Activity level ordered/documented

*Challenge = Time yourself and complete the above “EMR/Patient Documents” data collection in less than 30 minutes
upon opening the documents (30 minutes is an approximate time allotted for actual Handoff Report in the clinical setting).

STEP 2: Priority Setting

Use this tool for determining the order in which patient care should prioritized. Place the assigned patients in order of
priority and explain/rationalize your decision. (You may also consider: ABCs, Maslow’s, and The Nursing Process)
                                                                   Priority Setting Tool

Stable                                                                                                                                                            Unstable

_________DB____CS__________________________I_________________________________SC________
Expected                                                                                                                                                 Unexpected
_________DB______________________________I_____________________CS_______SC________________
Chronic                                                                                                                                                               Acute
_______________________________________I____________________CS_______DB____SC_____________
Non-Urgent                                                                                                                                                      Urgent
_______________________________________I____________________CS_____DB_______SC____________

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Potential Problem                                                                                                                             Actual Problem
_______________DB_____CS___________________I_____________________________SC_______________
                                                                  Neutral or No Information

Patient Initials/Room Why do you believe this is the order of priority?

Patient 1: SC I believe this patient is priority is priority because he has an issue of a possible bowel
obstruction that is a medical emergency that is happening now. He had fluid and electrolyte
imbalances. And was on the lookout for hypovolemic shock.
Patient 2: DB I believe this patient is a priority but less than the first patient because the patient is stable
but still has gone through an extensive surgery and has severe pain and loss large amounts
of blood which was 400 mL of blood. They should be monitored closely for complications that
can easily arise.
Patient 3: CS Although this patient was the highest priority later with his ventricular fibrillation rhythm at
first, he’s the last priority because he was stable and under control with medications.
Compared to the other patient he was less of a priority in the beginning.
Patient 4:

STEP 3: Noticing, Predicting and Managing potential complications: Applying the “Thinking Skill” to your
experience.
Answer the following questions related to your patient(s). You will need one chart (below) for each patient.
Noticing Projecting Predicting Managing
What are the important What are you on alert for What complications may What interventions will
observations and today with this patient? occur? What could go wrong? prevent complications and
assessments to make? improve clinical outcomes?
Stan Checketts

The patient had severe I am on alert for any Complications: 1. NPO as ordered.
abdominal pain, nausea, severe pain, Tissue Death 2. Insert a NGT to
and vomiting over the hypovolemic shock from Dehydration decompress the bowel as
last few days. the vomiting, abnormal ordered.
Abdominal is distended vitals and ECG. Fluid/electrolyte imbalance 3. Begin and maintain I.V.
because he has not therapy as ordered.
urinated since the day tissue death in the bowels 4. Administer analgesics,

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 prior. Hyperactive bowel broad spectrum
sounds. Dry mucous abscess within the antibiotics, antiemetics,
membranes. Sinus abdomen and other medication, as
Tachycardic. Skin is cold ordered.
and decreased skin kidney failure 5. Keep the patient in semi-
turgor. Hb high 20, high Fowler’s or Fowler’s
HCT 60, high WBC 17 a hole in the bowel, which position as much as
high Na+ 150, high Cl- could lead to infection. possible to promote
108, high BUN 42, high Peritonitis. pulmonary ventilation.
creatinine 1.9. 6. Look for signs of
Vitals: T:99, HR: 128, pulmonary aspiration, dehydration.
RR: 29, O2 sat: 90%, BP: 7. Monitor nasogastric tube 
107/77. Sepsis, a potentially fatal drainage for color,
blood infection consistency, and amount.
8. Monitor intake and
output.
9. Monitor vital signs
frequently.
10. When administering
medication, monitor the
patient for the desired
effects and for adverse
reactions.
11. Continually assess the
patient’s pain.

Why are these Comprehension: Relate the assessment data to How will the interventions
observations Why is this important? the potential complications prevent complications and
(perceptions) and that may occur. improve clinical outcomes?
assessments important?
These perceptions are Comprehension is The patient is experiencing Keeping him NPO because
important because it important for this patient severe abdominal pain, his intestines might be
could help provide a because it could help nausea, and vomiting from a impaired and to prevent any

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 better individualized with preventing any possible bowel obstruction. further damage. NGT to
patient care plan. And it further potential His labs were Hb high 20, high decompress the bowel and
helps the nurse provide complications that may HCT 60, high WBC 17 relieve the nausea and
the right documentation arise with Mr. Checketts high Na+ 150, high Cl- 108, vomiting. NS IV therapy
for the provider to create possible bowel high BUN 42, high creatinine because the patient is
the necessary orders for obstruction. Tissue death 1.9. These labs are related to suffering from dehydration
the patient. And help the or sepsis may occur if his fluid loss and dehydration and to prevent hypovolemic
nurse provide the right this condition isn’t from his vomiting. Also, his shock. Antibiotics to prevent
certain intervention they treated in a timely BUN and creatine are due to any infection that could lead
need now that is quick manner. So, it’s his urine retention that could to to sepsis. Elevate the head
and effective to prevent imperative that the nurse kidney failure if not treated of the bead for the patient to
any life-threatening can intervene as quickly soon. His respirations and breathe better. Monitor
complications that could as possible. It Could heart rate are compensating. intake and output to prevent
happen with this specific also prevent any Tachycardic and tachypneic. any renal complications from
patient. irreversible possible complications. And
complications from treat pain to prevent and
arising such as chronic worsening of the patient’s
kidney failure. condition.
Noticing Projecting Predicting Managing
What are the important What are you on alert for What complications may What interventions will
observations and today with this patient? occur? What could go wrong? prevent complications and
assessments to make? improve clinical outcomes?
Patient immediately I am alert for pain, and -Blood clots Monitoring kidney function.
came in after a total signs and symptoms of -Infection and sepsis Intake and output. And labs
abdominal hysterectomy bleeding and -Excessive Bleeding such as BUN and creatinine.
with bilateral salpingo- hemorrhaging, infection - Ureter damage, bladder, or Early ambulation
oopherectom. Pain is signs and symptoms, bowel damage Frequent vitals and
severe at 6/10 in the and ECG rhythms. -vaginal problems assessments.
abdominal region. -Evisceration and dehiscence Controlling pain
Abdominal incision is -Shock Watch for infection
intact with no drainage. -DVT and PE Balance nutrition
Sinus Tachycardic. Skin Administer medications such
is cool and sweaty. as pain meds as ordered
Vitals: T:99, HR:111, Splint abdomen if patient

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 BP: 154/92, RR: 21, O2 needs to sneeze or cough
sat: 93% Balance nutrition
Incentive spirometer
Why are these Comprehension: Relate the assessment data to How will the interventions
observations Why is this important? the potential complications prevent complications and
(perceptions) and that may occur. improve clinical outcomes?
assessments important?
These perceptions are Comprehension is The patient is in 6/10 pain 1. Maintaining Normal
important because it important for this patient related to her surgery. Her Elimination Patterns
could help provide a because it could help skin is cool and sweaty from 2. Controlling pain - a client
better individualized with preventing any the blood loss from surgery. who is comfortable will be
patient care plan. And it potential complications Her heart rate and blood able to participate in the
helps the nurse provide that may arise with Ms. pressure are compensating. post-op regimen
the right documentation Bowman’s abdominal Blood pressure is high 3. Watch for infection to
for the provider to create hysterectomy. Infection (154/92) and heartrate is high prevent life-threating sepsis.
the necessary orders for or sepsis may occur if (111). Watch for distention,
the patient. And help the this condition if there redness, swelling, and pain.
nurse provide the right isn’t any close 4. Balanced nutrition
certain intervention they monitoring. So, it’s because client’s metabolic
need now that is quick imperative that the nurse needs are high, but there is a
and effective to prevent can do close monitoring decreased desire/ability to
any life-threatening of potential ingest and digest food.
complications that could complications and 5. Assure that electrolyte
happen with this specific manage pain as for the levels are balanced
patient. patient. It could also 6. Incentive spirometer use
prevent any irreversible to prevent infection and
complications from atelectasis
arising. 7. Splinting prevent
dehiscence and evisceration
8. Anticoagulant and fluids

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 Noticing Projecting Predicting Managing
What are the important What are you on alert for What complications may What interventions will
observations and today with this patient? occur? What could go wrong? prevent complications?
assessments to make?
Patient has undergone a I am on alert for any  Complication: 1. Assess for chest pain
Carl Shapiro

myocardial infarction and dysrhythmias, chest Disturbance of rate, not relieved by rest or
Had a 2/10 pain before pain, and alterations of rhythm and conduction. medications.
Nitroglycerin has been vital signs. Also, any  Cardiac rupture. 2. Monitor vital signs,
given. His pain is at a irregular heart and lung  Cardiogenic Shock especially the blood
0/10 now. His labs CK- sounds.  Angina Pectoris pressure and pulse
MB, troponin, and  Thromboembolism rate.
creatinine levels are  Heart failure. 3. Assess for presence
elevated. His oxygen is  Pericarditis. of shortness of breath,
4L/min per nasal  Ventricular septal dyspnea, tachypnea,
cannula. Went into V-fib defect. and crackles.
during assessment.  Ventricular aneurysm. 4. Assess for nausea
Vitals: T: 99 HR:82 O2  Ruptured papillary and vomiting.
sat: 97% RR:12 B/P: muscles. 5. Assess for decreased
121/72  Dressler's syndrome. urinary output.
 Depression 6. Assess for the history
 Acute kidney failure of illnesses.
7. Perform a precise and
complete physical
assessment to detect
complications and
changes in the
patient’s status.
8. Assess IV sites
frequently.
Why are these Comprehension: Relate the assessment data to How will the interventions
observations Why is this important? the potential complications prevent complications?
(perceptions) and that may occur.
assessments important?

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 These perceptions are
important because it
could help provide a
better individualized
patient care plan. And it
helps the nurse provide
the right documentation
for the provider to create
the necessary orders for
the patient. And help the
nurse provide the right
certain intervention they
need now that is quick
and effective to prevent
any life-threatening
complications that could
happen with this specific
patient. V-fib is a serious
issue that needs to be
address immediately
before death occurs.
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Comprehension is His Ventricular tachycardia is 1. Administer oxygen
important for this patient a data assessment that could along with medication
because it could help show a potential complication. therapy to assist with
with preventing any He was stable after the acute relief of symptoms.
potential complications myocardial infarction. His 2. Encourage bed rest
that may arise with Mr. troponin, CK-MB, and with the back rest
Shapiro’s acute creatinine are elevated. His elevated to help
myocardial infarction vitals were stable prior to the decrease chest
and later Ventricular ventricular tachycardia. discomfort and
fibrillation. So, it’s dyspnea.
imperative that the nurse 3. Encourage changing
can do close monitoring of positions frequently
of potential to help keep fluid from
complications and pooling in the bases
manage pain as for the of the lungs.
patient. It could also 4. Check skin
prevent any irreversible temperature and
complications from peripheral pulses
arising. frequently to monitor
tissue perfusion.
5. Provide information in
an honest and
supportive manner.
6. Monitor the patient
closely for changes in
cardiac rate and
rhythm, heart sounds,
blood pressure, chest
pain, respiratory
status, urinary output,
changes in skin color,
and laboratory values.
STEP 4: Comprehension: Critical Thinking (how much ambiguity is involved):
Answer the following questions related to all assigned patients (comparing and contrasting).
Patient

In what ways are the In what ways would In what ways are the 3
patients similar? their nursing care be patients different?
similar?
All of the patients needed The ways the nursing
to be closely monitored care for the patients
before any life-threatening were similar in that the
situations occur. And the patient needed oxygen,
patient’s conditions were their head of the bed
acute and urgent. raised. Two of the
three patients needed
their pain and nausea
to be relived.
How would their care be
different? Why?
One patient needed a nasal
gastric tube to be administer
and needed to be administer
fluids because of fluid
volume deficient due to the
bowel obstruction. Another
patient needed to be
monitored closely for
hypovolemic shock and
respiratory depression event.
after an extensive surgery.
And the last patient needed
to be monitored closely and
given oxygen after their
acute myocardial infarction
and treated immediately
when they went into
ventricular fibrillation.
Mr. Checketts needs to be
monitored for any fluid and
electrolyte balances due to his
bowel obstruction and will be
placed on a NGT. Ms.
Bowman needs to be
extensively monitored after her
surgery she loss 400 mL of
blood which puts her at risk for
hypovolemic shock. And after
her respiratory depression
event. Mr. Shapiro assessed
closely following his ventricular
fibrillation with antiarrhythmics
and frequent assessments.

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STEP 5: Medications
Complete medication information related to your patients. You may add all the medications you administered or were
included in patient report/care to this chart.
Generic, Classification Effect on Patient Education & Nursing Considerations and Interventions for
Dose, Time & VS, administration
Route Diagnosis
and Pre-
Existing
Conditions

opioid Respiratory  Medication may cause drowsiness or dizziness. Educate patient to

Buprenorphin analgesics depression, call for assistance when ambulating and to avoid driving or other
e, 0.3 mg, headache, activities requiring alertness until response to medication is known.
1351, IV dizziness,  Advise patient to avoid concurrent use of alcohol or other CNS
confusion, depressants.
hypotension  Instruct patient to notify health care professional of all Rx or OTC
, sweating, medications, vitamins, or herbal products being taken and to consult
nausea health care professional before taking any OTC medications
concurrently with this therapy.
 Pain: Instruct patient on how and when to ask for pain medication.
 Encourage patients on bedrest to turn, cough, and deep-breathe
every 2hr to prevent atelectasis.
 Instructpatienttochangepositionsslowlytominimizeorthostatichypoten
sion.
 Advise patient that good oral hygiene, frequent mouth rinses, and
sugarless gum or candy may decrease dry mouth.

Ondansetron, antiemetics Constipation  Take medication as directed

4 mg, 1319, , diarrhea,  Tell HCP if irregular heartbeat and involuntary movement occurs.
IV dizziness,
drowsiness,
fatigue, and
headache

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 Morphine, 2 mg, opioid Respiratory  Patient Education on how and when to ask for pain medication. May
1104, IV analgesics depression, cause drowsiness or dizziness. Caution patient to call for assistance
confusion, when ambulating or smoking and to avoid driving or other activities
sedation, requiring alertness until response to medication is known. Advise
dizziness, patient to change positions slowly to minimize orthostatic
and hypotension. Avoid alcohol. Encourage patients who are
constipation, immobilized or on prolonged bedrest to turn, cough, and breathe
and deeply every 2 hr to prevent atelectasis.
hypotension
Naloxone, 0.2 antidotes (for Ventricular  As medication becomes effective, explain purpose and effects of
mg, 1323, iV opioids) arrhythmias, naloxone to patient.
seizures,  Therapeutic communication after treatment and patient is stable.
hypertensio
n,
hypotension
, nausea,
and
vomiting.
Amiodarone antiarrhythmic dizziness,  Instruct patient to take amiodarone as directed
s fatigue,  Educate patient to avoid drinking grapefruit juice
malaise,  Teach patient to monitor pulse daily and report abnormalities
bradycardia,
hypotension
, and
constipation

Aspirin antipyretics, dyspepsia,  Advise patient to report tinnitus; unusual bleeding of gums; bruising;
nonopioid epigastric black, tarry stools; or fever lasting longer than 3 days.
analgesics distress,
nausea,  Take a Full glass of water and avoid alcohol
anemia,
hemolysis

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 Epinephrine antiasthmatic nervousnes  Instruct patient to contact health care professional immediately if
3-5 minutes s s, shortness of breath is not relieved by medication or is accompanied
restlessness by diaphoresis, dizziness, palpitations, or chest pain.
, tremor,  Drink 2-3 fluids per day
angina,
arrhythmias,
hypertensio
n,
tachycardia.
Nitroglycerin Nitrates Dizziness,  Caution patient to change positions slowly to minimize orthostatic
headache, hypotension. First dose should be taken while in a sitting or
hypotension reclining position, especially in ger- iatric patients.
,  Advise patient to avoid concurrent use of alcohol with this
tachycardia, medication. Patient should also consult health care professional
and before taking OTC medications while taking nitroglycerin.
syncope  inform patient that headache is a common side effect that should
decrease with continuing therapy. Aspirin or acetaminophen may be
ordered to treat headache. Notify health care professional if
headache is persistent or severe.
Vasopressin antidiuretic  Avoid taking alcohol with the medications
hormones,  Should carry a medical identification
vasoconstrict  Advise patient to drink 1-2 glasses of water
or

STEP 6: Projection and Evaluation: Create a Plan of Care for each patient (ranking at least 3 problems in order of
priority)
Create a plan of care for each patient (include goals, interventions and evaluation methods).
Goals should be SMART: The "SMART" acronym stands for specific, measurable, attainable, relevant, and timely. Each
SMART goal you create should have these five characteristics to ensure the goal can be reached and benefits the patient.
Stan Checketts
Nursing Diagnoses
Deficient fluid volume related to decrease intestinal fluid absorption and loss of fluids as evidence by patient vomiting.

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Acute pain related to distention and rigidity as evidence by patient rates 4/10 on pain scale and sates abdominal cramping
and tenderness in abdomen.
Risk for Infection related to the development of inflammatory process or worsening bowel obstruction.
Nursing Interventions
Assess level of pain and administer medications as ordered.
Have patient maintain limited bedrest and activity
Non-pharmacological measures to assist with control of pain like biofeedback and guided imagery.
Asses vitals closely especially temperature. Assess mental status and levels and level of consciousness closely. Monitor
lab values like WBC if its elevated.
Monitor patient for signs of dehydration and electrolyte imbalance.
Fluids should be administered as ordered
Nursing goals
Client will report a decrease in pain from 8 to 0 on the pain by discharge
Client will remain free of signs and symptoms of infection.
Client fluid volume will be maintained before discharge.

Doris Bowman
Nursing diagnosis
Infective breathing pattern related to opioid intoxication as evidence by respirations dropped to 7 breaths per minute.
Acute pain related to recent hysterectomy as evidence by patient reporting 6 out of 10 pain in the abdominal region.
Risk for infection related to broken skin due to surgery
Nursing Interventions
Administer medications such as naloxone. Assess respiratory rate, depth, and breath sounds for any adventitious sounds.
Initiate the turn, cough, and deep breathe. Elevate head of bed and early ambulation. And administer oxygen as ordered.
Evaluating pain regularly. Frequent assessments and vital signs. Nonpharmacological methods to reduce pain like
positioning, deep-breathing exercises, guided imagery, visualization, and music
Adhere to facility infection control, sterilization, and aseptic policies and procedures.
Assess incision site for any redness, swelling, purulent drainage, and warmth. Administer any antibiotics as ordered.
Nursing Goals
Client will mention a 2/10 pain before the end of the shift.
Client will establish a normal/effective respiratory pattern free of cyanosis or other signs of hypoxia.
Client will remain free of signs and symptoms of infection.

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Carl Shapiro
Nursing diagnosis
Ineffective tissue perfusion (myocardial) related to interruption of blood flow as evidence by elevation of creatine and BUN
levels.
Activity Intolerance related to recent imbalance between myocardial oxygen supply and demand as evidence by
development of ventricular fibrillation.
Risk for decreased cardiac output related to change in rate, rhythm, electrical conduction
Nursing Interventions
Monitor ECG, vital signs for alterations, administer medications. Promote rest for the client.
Encourage rest initially. Thereafter, limit activity on basis of pain and/or adverse cardiac response. Provide nonstress
diversional activities. Assess vital signs.
Maintain hemodynamic stability, evaluate vital signs, and administer medications.
Nursing Goals
Client will demonstrate an absence of any dysrhythmias before discharge.
Client will maintain adequate perfusion before the end of shift.
Client will demonstrate a progressive increase in tolerance for activity.
STEP 7: Managing: Patient Education and Discharge Topics
List 3 (or more) topics related to each patient’s current status.
Include how the topics shall be taught (ex. give patient literature or demonstration by nurse).
Include statements about how each of the education topics should be evaluated for patient comprehension?

Stan Checketts
Follow up care visits with physicians. Discharge medications educations. Colostomy care education is it has been placed.
Signs and symptoms to call the physician for. Diet, Exercise, and Other Lifestyle Changes. (Literature, discussion, teach-
back method).

Doris Bowman
Follow up visits and referrals. Medication, diet, and activity education. Incision and drain care. Signs and symptoms to call
the doctor. (Literature and teach back method with nurse, and therapeutic communication).

Carl Shapiro

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Be sure the patient understands all the medications, including the dosage, route, action, and adverse effects. Instruct the
patient to keep the nitroglycerin bottle sealed and away from heat. Educate on administration of nitroglycerin and how to
store it.

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