Case #1- Mr.

Oulton Grad- Anxiety IP#1212123 You enter your patient’s room to

perform HS care. Your patient states, "I feel so helpless. I feel like I will never feel
better and nobody can help me."

Date Time Focus Data, Action, Response, Plan

Bedtime Care "I feel so helpless. I feel like
I will never feel better and
nobody can help me."

A:
- Approached the patient with
a calm and reassuring
demeanor.
- Provided the patient with
privacy and ensure a calm
and quiet environment for
bedtime.
- Assessed the patient's
comfort level, asking about
any pain, discomfort, or
specific concerns related to
bedtime care.
- Assisted the patient with
any necessary hygiene
activities, such as brushing
teeth, washing face, and
using the toilet.
- Ensured that the patient's
bed linens are clean, dry, and
comfortable.
- Helped the patient change
into clean and appropriate
sleepwear.
- Ensured the patient's room
is adequately ventilated and
at a comfortable temperature.
- Assisted the patient in
getting into a comfortable
position for sleep,
considering any mobility
limitations or positioning
preferences.
- Provided necessary pillows,
blankets, or other comfort
items to support the patient's
sleep.

R:
- Patient expressed gratitude
for being heard and
acknowledged.
- The patient appreciated
being provided with privacy
and a calm and quiet
environment for bedtime.
- The patient expressed
gratitude for the nurse's
assessment of comfort and
appreciated being asked
about any pain, discomfort,
or concerns related to
bedtime care.
- The patient thanked the
nurse for assisting with
hygiene activities, including
brushing teeth, washing face,
and using the toilet.
- The patient was pleased to
have had clean, dry, and
comfortable bed linens.
- The patient expressed
satisfaction with the nurse's
help in changing into clean
 and appropriate sleepwear.
- The patient acknowledged
the nurse's efforts to ensure
the room was adequately
ventilated and at a
comfortable temperature.
- The patient felt grateful for
the nurse's assistance in
getting into a comfortable
position for sleep,
considering any mobility
limitations or positioning
preferences.
- The patient appreciated the
provision of necessary
pillows, blankets, or other
comfort items to support their
sleep.

P:
- Reassess the patient
periodically throughout the
night, addressing any
emerging needs or concerns.
- Communicate any
significant findings or
changes in the patient's
condition to the healthcare
team during shift handover.
- Maintain regular follow-up
and ongoing assessment to
ensure the patient's bedtime
care needs are met
effectively.

Case #2- Ms. Imma Nurse IP#5065067 You are walking down the hallway of your
unit and hear a commotion. You are working on the stroke unit and so far, it has been
a quiet evening. Many patients require assistance on this unit with care, and many are
angry and confused. Most have settled into bed for the night until you hear a patient
yelling from room 4612. Upon entering the room you soon realize that the patient
from room 4606 has wandered into 4612; where a stroke patient lies helpless in bed
with the angry wandering patient yelling "I know you took my slippers!! Where have
you put my slippers!!"

Date Time Focus Data, Action, Response, Plan

Patient’s Safety "I know you took my
slippers!! Where have you
put my slippers!!"

A:
- Entered room 4612 calmly
and assessed the situation to
ensure the safety of both
patients.
- Engaged in active listening
to understand the wandering
patient's concerns and
frustrations about the missing
slippers.
- Demonstrated empathy and
reassurance, acknowledging
the wandering patient's
feelings and validating their
experience.
- Used effective
communication techniques to
de-escalate the wandering
patient's agitation, such as
 speaking in a calm and
reassuring tone and
maintaining a non-
confrontational posture.
- Ensured the physical safety
of both patients by creating a
safe distance between them,
ensuring no harm or further
distress occurred.

R:
- Patient expressed
appreciation for the nurse's
calm and understanding
presence.
- Patient felt heard and
understood, which helped
alleviate their agitation and
frustration.
- Patient reported feeling
more at ease and reassured by
the nurse's empathetic
approach.
- Patient expressed gratitude
for the nurse's efforts to
ensure their safety and
prevent any escalation of the
situation
- Patient complied with the
nurse's instructions to
maintain a safe distance from
the other patient.

P:
- Ensure the ongoing safety
and well-being of both the
wandering patient and the
stroke patient.
- Address the wandering
patient's emotional distress
by involving a mental health
professional for evaluation
and support.
- Enhance communication
and coordination among the
unit staff to promptly respond
to any future incidents
involving wandering patients.
- Consider implementing
additional interventions, such
as visual cues or familiar
objects, to help reduce
confusion and agitation in
patients with wandering
tendencies.

Case #3- Mr. Urine Nation IP#9595646 You enter your patient’s room at 1230h to set
him up for lunch and realize there is only 10mls of urine in his drainage bag.
(Critically think-this may require more than one DARP. Start from the beginning,
what should you do first?)

Date Time Focus Data, Action, Response, Plan

For lunch D:

A:
- Prepared and provide a
balanced and appropriate
lunch meal for the patient
based on their dietary needs
and recovery status.
 - Ensured the meal is visually
appealing and appropriately
portioned to meet the
patient's nutritional needs.
- Labeled the lunch tray with
the patient's name and room
number for proper
identification and delivery.
- Delivered the lunch tray to
the patient's room promptly
at the scheduled mealtime.

R:
- The patient expressed
gratitude for the
consideration given to their
dietary needs and recovery
status.
- The patient commented on
the appealing presentation of
the meal and appreciated the
appropriate portion sizes.
- The patient confirmed that
the lunch tray was correctly
labeled with their name and
room number, ensuring
proper identification.
- The patient acknowledged
the timely delivery of the
lunch tray and expressed
satisfaction with the
punctuality of the service.

P:
- Monitor the patient during
the meal for any signs of
discomfort, difficulty
swallowing, or adverse
reactions to the food.
- Report any concerns or
changes in the patient's
condition to the appropriate
healthcare provider.
- Follow up with the patient
after the meal to assess their
satisfaction and address any
additional needs or questions.

Case #4- Ms. Toasty Warm IP#7744123 You are checking routine vital signs and
your patient states "I feel sweaty, can you turn down the heat?" The oral temperature
you obtain is 39.4*C

Date Time Focus Data, Action, Response, Plan

Temperature regulation and D:
patient comfort. - "I feel sweaty, can you turn
down the heat?"
- Oral temp: 39.4

A:
- Assessed the patient's
overall condition,
appearance, and skin color
for signs of distress or
discomfort.
- Checked the patient's pulse
rate, respiratory rate, and
blood pressure to complete
the assessment.
- Evaluated the patient's
hydration status by assessing
their skin turgor and mucous
membranes.
 - Adjusted the room
temperature to a more
comfortable level.
- Provided the patient with a
cool cloth or fan to help
alleviate the sensation of
sweating.

R:
- Patient appreciated the
nurse's attentiveness in
assessing their overall
condition and appearance.
- Patient expressed gratitude
for the nurse's actions in
addressing their sensation of
sweating and discomfort.
- Patient participated in the
following assessments.
- Patient expressed relief and
comfort after the room
temperature was adjusted.
- Patient reported feeling
more comfortable and less
distressed after receiving the
cool cloth or fan.

P:
- Monitor the patient's vital
signs regularly to assess for
any changes or
improvements.
- Continue to assess the
patient's comfort level and
response to interventions.

Case #5- Mr. Epi Dermis IP#8956231 During afternoon rounds, you turn and
reposition your patient as per the Q2H turn schedule your patient is on for poor skin
integrity. The patient rolls over and his arm slips between the mattress and the bedrail
causing a minor skin tear.

 Afternoon rounds
Date Time Focus Data, Action, Response, Plan
Afternoon rounds D:

A:
- Assessed the patient's lung
sounds using a stethoscope
and note any abnormal
findings such as crackles or
diminished breath sounds.
- Measured the patient's
temperature using a
thermometer to monitor for
changes in body temperature.
- Checked the patient's blood
pressure using a blood
pressure cuff to assess their
cardiovascular status.
- Administered the prescribed
medication orally.
- Offered the patient a glass
of water and provide
assistance with sips if needed
to ensure adequate hydration.
- Provided emotional support
and address any non-medical
needs or concerns the patient
may have.
 R:
- The patient reported feeling
less congested and noted
improved breathing.
- The patient asked about the
purpose and potential side
effects of the medication.
- The patient's blood pressure
remained stable within the
normal range, and no
symptoms of dizziness or
lightheadedness were
reported.
- The patient expressed
appreciation for the
assistance with hydration and
mentioned feeling less thirsty
after drinking water.
- The patient asked about
additional measures they
could take to promote their
recovery.
- The patient expressed
gratitude for the emotional
support and stated feeling
more at ease and reassured
after the visit.

P:
- Continuously document the
patient's progress, response to
interventions, and any
changes in their condition in
their medical chart, ensuring
accurate and updated
information for the
healthcare team.

 Poor skin integrity

Date Time Focus Data, Action, Response, Plan
Poor skin integrity D:
- poor skin integrity
- skin assessment reveals
areas of redness

A:
- Performed a comprehensive
skin assessment, noting the
location, size, and
characteristics of the existing
wounds or areas of
breakdown.
- Implemented a regular
turning (Q2H) and
repositioning schedule to
relieve pressure on
vulnerable areas.
- Applied appropriate
dressings or treatments to
promote wound healing and
protect the skin.

R:
- Patient expressed
appreciation for the thorough
skin assessment.
- Patient reported relief and
comfort after being turned
and repositioned regularly.
- Patient acknowledged the
nurse's efforts in applying
appropriate dressings or
 treatments to promote
healing and protect the skin.

P:
- Continuously monitor the
patient's skin integrity and
document any changes or
progress.
- Encourage the patient to
actively participate in their
care by notifying the
healthcare team of any
changes in skin condition or
discomfort.

 General Assessment (head-to-toe assessment)

Date Time Focus Data, Action, Response, Plan
Head-to-toe assessment D:
- minor skin tear

A:
- Performed a head-to-toe
assessment:
- Assessed the patient's level
of consciousness, pupil
reaction, and signs of trauma
or abnormalities in the head.
- Checked for neck stiffness,
swelling, or cervical spine
tenderness.
- Observeed breathing
patterns, lung sounds, and
signs of trauma or
deformities in the chest.
- Palpated the abdomen for
tenderness, distension, or
abnormalities.
- Evaluated the pelvis and
genital area for signs of
injury, bleeding, or
abnormalities.
- Examined the extremities
for fractures, dislocations,
deformities, or other injuries.
- Inspected the back for signs
of trauma, bruising, or
wounds.
- Provided immediate first
aid for the minor skin tear:
- Cleanse the wound gently
with sterile saline or mild
antiseptic solution.
- Applied a sterile dressing or
bandage to protect the wound
and prevent further
contamination.

R:
- Patient expressed
cooperation and complied
with the head-to-toe
assessment.
- Patient reported no
discomfort or abnormalities
during the assessment of the
head.
- Patient did not experience
any neck stiffness, swelling,
or cervical spine tenderness.
- Patient had normal
breathing patterns and no
signs of trauma or
deformities in the chest.
- Patient did not exhibit
tenderness, distension, or
abnormalities in the
abdomen.
- No signs of injury,
bleeding, or abnormalities
were found in the pelvis and
genital area.
- Patient had no fractures,
dislocations, deformities, or
other injuries in the
extremities.
- No signs of trauma,
bruising, or wounds were
observed on the back.
- Patient cooperated during
the cleaning of the skin tear
and reported minimal pain.
- Patient appreciated the
nurse's application of a sterile
dressing to protect the
wound.
- Patient expressed gratitude
for the prompt first aid
provided.

P:
- Regularly document any
changes or improvements in
the patient during subsequent
head-to-toe assessments.