Case evaluation sheet – Critical thinking

Safety
Hand Hygiene before and after entry into room EHR considered in room- Med Pyxis is considered outside of room

Wears appropriate PPE – think covid! Mask, gloves, gowns- cough, - blood, drainage, Cdiff, etc.
Checks ID band – are you working with the right person? Done upon entry into room
Ergonomic and safety and repositions patient-(ie HOB elevated for SOB, comfort, side rails up and down, bed lock applied, Tell patient not to get up
without you, socks ,signs, table next to bed, call light in reach)
Medication rights-(right patient, time, route, drug and dose) Missing any of these elements results in redo
Blood administration- 2 nurse at bedside, just before administration then document- failure results in auto REDO
Med administration documentation- doc after giving med. Missing or in wrong order- REDO
Medication education you gave drug- did you teach about it?
Actions/Instructs regarding preventions- instructs on not to get OOB without help (in beginning of case unless emergent RX required. Call lights, side tables
closer , signs, socks ect- can be at end of case.
Assessment - RNs assess BEFORE TX
Gathers information- gets Report/ Listens to patient/ Looks at EHR – EHR related to DX(.ie Pt bleeding- H&H, Chem, Resp- ABG’s Infection CBC) must review
pertinent Labs, Diagnostics and medical HX, allergies BEFORE treatment except- O2, CPR, Code,

Check Vitals signs, Examine, Listen to Pt, check O2 and IV pump- beginning, & after every intervention
Completes exam when appropriate – see above and re examines when appropriate
Assess for pain (5 th vital sign) with vitals or at least once in scenario
Critical Thinking
Identifies and interprets findings (labs, CT, Xray, exam) labs important to DX and assessment/treatment-
Prioritizes interventions based on findings- putting it all together-
Appropriate actions/interventions done -ie patient SOB -elevate HOB, mouth care, skin care, care as per the lesson- reflected in actions, and nursing
interventions, assessment, reassessment
Evaluates interventions- reassessment of actions Remember Nursing process- Assessment, diagnosis, planning, implementation, and evaluation
Interventions – using Lesson info RN interventions, care and education is related to patient problem.
Notes changes in patient- reassessment after each intervention
 Administers correct meds
Adjusts /stops/medication dosage/fluid volume
Adjust 02 per pt needs/reevaluates
Provides wound/dressing care/ foot care/ surgical wound
Adjust bed / Repositions if needed
Fall risk - Move call light closer. Instruct not to get OOB, sign above bed, slip proof socks
Provides patient activity instructions makes appropriate referrals
Oral care, perineal care, suctioning, other

Look at each assignment to complete- your interventions must address whole patient and their problems or any co-morbidly that affects patients ability to
care for self
Missing elements will result in REDO
Patient Education – must relate to problem, treatment, co-morbities, CV,
Mental, GI, Hygiene

Nursing interventions/Comfort Relate to case /HX – HOB elevate ICP/SOB , diarrhea,

measures incontinence, oral care(vent- steroids), wound care ,
Prevention of Never events - must relate to problem
Core Measures/Best practices - Look at Lesson - Med/Nurs
interventions/recommendations
Vaccines(everyone)- stop smoking, activity, rehab,
Handwashing, Diet
Must reflect primary and co-
Spiritual /Psychosocial Counseling, rehab, substance abuse, abuse, end of life
etc.
REFERRALS ALSO Referrals- RRT / Social Worker/ Case mgt/
Depression screen/ counseling/ wound mgt
Student worksheet- every case- notes for participation in debriefing- bring with you to debriefing.

o
 Handwashing
 Face mask
 Gloves
 Patient ID/Verification
 Verify Patient Name & DOB
 Check Patient ID Band
 Scan Patient's Arm Band
 Scan Medication (TAKE A SCREENSHOT OF THIS TAB ON NOVEX & SUBMIT THIS ON CANVAS)
 Verify Medication Dose
 Verify Medication Administration Time
 Verify Medication Administration Route
 Listen to Patient
 Vital Signs/Exam
 Oxygen
 Infusion Pump
 Point of Care Machine
 Bed Control tabs (2 locations)
 Patient Education Button
 General Button
 Medication Use & Side Effects (TAKE A SCREENSHOT OF THIS TAB ON NOVEX & SUBMIT THIS
ON CANVAS)
 Patient Intervention Button
 Comfort Care
 Assess for Pain or Discomfort
 Provide Spiritual Music
 Provide emotional Support
 Safety & Quality
 Monitoring & Preventing Never Events
 Prevent Falls & Trauma  (TAKE A SCREENSHOT OF THIS TAB ON NOVEX & SUBMIT
THIS ON CANVAS)
 Prevent Pressure Ulcer
 Patient Activity Instructions
 Deep Breath, Exhale & Hold
 Explain Need to Call for Help Prior to Exiting Bed
 Medication Cart Button
 Listen to Family Button
 Patient Report/Chief Complaint Button
  Electronic Health Record (EHR) Button
 Medical History
 Medications
 Laboratory Information
 Diagnostics/Reports
 Code Status

 Address urgent and high priority patient needs - (ABCs, Maslows, logical prioritization, etc...)
 Engage in safe nursing practice- (wash hands, PPEs, check pt verifiers, Rights of medication administration, etc..)
 Identify everything that you would do in an actual patient care environment and implement the nursing process- (Imagine
you are in the patient's room, try to reflect everything that you would actually do like bring the rail up & down, put the brake on the
bed, introduce yourself, explain to the patient what you're doing/plan of care, etc...).
 Complete 4 Interventions that address and prevent  Never Events/Sentinel Events
 Complete 4 Patient Education Interventions
 Complete 3 Comfort Care Interventions
 Complete 2 Spiritual Care Interventions

Handwash in/out

Every time you do an intervention go back and re check

If pt is not doing well COC call RRT, call RT, PT, social worker/ case manager

Check O2, physical exam

EHR- check meds on EHR before giving meds

Before giving meds check allergy band, check xray, diagnostics, v/s, hx (if COPD cant have too much O2), electrolytes (Na, K+), H & H

If they have a wound, examine, do wound care, call wound nurse

Look at their comorbidities, if diabetic, CAD, wound look at diet

Core measures: Educate: vaccines, prevention, safety, smoking cessation, activities, diet, SCD, DVT prophylaxis, med side effects, when
to recognize complications, call 911, prevent re admission
Never give vasopressor until normovolemic MAP >65

Not moving: PT

Change in LOC: not talking, stopped eating/drinking

Wash hands, PPE (FULL), name band/allergy, apply fall risk, lock bed

V/S, low BP, elevate legs re check BP, exam, check IV

Call RRT (low BP, not responding)

Check EHR, diagnostics, labs, meds, hx

Give NS IV

Handwash, ID, scan name, med, 5 rights, document, re check pt/exam

Handwash out

Med cart, albumin

Handwash in, name band, 5 rights, document

Re check vs, exam

Possible referrals

Nursing interventions, safety, call light, bed table, comfort care, check pain, keep family updated, religious teaching

Complication prevention, hygiene, activity instructions, explain fall precautions to family, med instructions, toileting, explain what youre
doing, reposition,

prevent never events: falls, dvt, pressure ulcer, readmission

med education, dvt prevention

dc instructions, advance directives, vaccines, med use and side effects, complications
call case manager, PT

wash hands

finish case

diet

Blood: do intervention outside of room, 2 nurse check inside room

Check Iv pump/access

If hgb low> iron diet

Give Ns

After giving fluids, do point of care, check electrolytes