12. Later in the shift, the nurse is looking through Ms. Winnie’s chart and comments to herself.

“I think I
may have reviewed the policy and procedure book for nothing.” Why does the nurse believed she may
not need to know how to administer blood to Ms. Winnie after all?

The nurse is incorrect. Even though Ms. Winnie is a Jehovah Witness she has the right to choose
if ever their will be blood transfusion to do or reconsider the procedure, must a think to consider as a
nurse.

13. Which aspects of Ms. Winnie’s plan of care could the registered nurse assign to assistive nursing
personnel such as a certified nursing assistant?

Recording I & O hourly- to monitor fluid balance.

14. Should Ms. Winnie be concerned about her job? What do you anticipate will be her length of stay in
the hospital?

No, Ms. Winnie should not be worried about her job. The Mallory-Weiss tear is an emergency
and must be resolved before she can return to work. It can cause great risk for bleeding so stat
treatment is needed to prevent the possible risk that she may be able to get back at work after the
treatment soon as it is treated.

DATE/TIME FOCUS DATA:

MARCH 26, 2021 Hyperthermia -Patient verbalize “I have been
8:00 am so sick. It must be flu.”
-Temperature of 100.5 F (38 C)
ACTION:
-Tepid sponge bath done
- instructed the let patient to
wear loose clothing
- instructed to let patient drink
lots of fluid
- provided opportunity for
patient to rest
- due meds given
- PRN Paracetamol administered
RESPONSE:
10:00 am - patient was able to rest
- patient temperature decrease
to T= 37.8 C
- IV score = 0

DATE/TIME FOCUS DATA:

MARCH 26, 2021 Vomiting - Patient verbalize “I keep
8:00 am vomiting and have not been
able to keep anything down for
the past three days.”
 - Her skin is clammy and pale.
- Vomited twice within three
hours.
- Report of red like blood
vomitus.
ACTION:
- Provided an emesis basin
within easy reach of the patient.
- Assisted the patient in
diagnostic testing preparation.
- Maintain fluid balance in
patients to prevent risk for
dehydration.
- Positioned the patient upright
while eating and for 1 to 2
hours post-meal.
- Administered antiemetics as
ordered.
- Keep rooms well-ventilated.
- Educated the patient to take
prescribed medications as
ordered.
RESPONSE:
12:00 pm - “I feel like better now” as
verbalize by the patient.
- No report of vomiting after
intervention.
- No signs of dehydration.
- Patient is awake and alert
when asked about his feeling.
- IV score = 0

DATE/TIME FOCUS DATA:

MARCH 26, 2021 Medication Education - Patient is taking Ortho Tri-
10:00 am cyclen, Advil, Protonix,
Compazine, and Prilosec
ACTION:
- Educated the patient about
the drugs she taking in and the
possible side effects on each
drug and observed safety
precaution.
- Advised the patient to
discontinue Advil that may be
the cause of the GI problem.
10:30 am RESPONSE:
- Patient able to understand the
 medication education as she
was able to repeat the nurse’s
instructions.
- Patient verbalized correctly
side effects and safety
precautions.

DATE/TIME FOCUS DATA:

MARCH 27, 2021 GI STATUS - ECG shows normal sinus
7:00 am rhythm.
- KUB reported with no acute
abnormality.
- EGD reveals normal
duodenum.
- A small Mallory-Weiss tear is
noted.
ACTION:
- Maintain fluid balance in
patients to prevent risk for
dehydration.
- provided opportunity for
patient to rest
- due meds given
RESPONSE:
2:00 pm No GI upset reported during
shift.
IV score = 0

DATE/TIME FOCUS DATA:

MARCH 27, 2021 -
7:00 am ACTION:
-
RESPONSE:

IV score = 0
2:00 pm