PRACTICE SCENARIO

You are working day shift and your 27 yo ,Mary Lou was admitted to the Ortho unit around 5pm after an MRI revealed a cervical cord mass. She is experiencing weakness, is ataxic and has neck and back pain. Her pain score is a 5 with morphine on board. She is scheduled for a cervical laminectomy tomorrow. She is a single mother and concerned about her 4 and 2 year old children and how she will care for them after surgery.

  1. Select and Save Pathway ( StarPanel)

Cervical Surgery (Ortho)

To select a training census and patient.

  1. Document Pathway Name & Phase (HED)

REMEMBER TO USE HED TRAIN

Notice that the cervical surgery pathway does not have a preop phase so pick the best fit – Day of Surgery since the pt is going for surgery tomorrow.

Cervical Surgery (Ortho) Phase: Day of surgery

  1. Create 2-3 Priority Problems (HED) and Define Expected outcomes (long term goals) for each problem

Pain

Acute pain related to neck mass

Expected outcome: improved

Self Concept

Feat related to neck mass biopsy and care of children post op

Expected outcome: improve

Safety

Injury Risk Other related to ataxia and narcotics for pain; potential to fall Expected outcome: improved

  1. Enter a Nursing Summary and Plan Priorities for the next shift since it is almost shift change time.

Summary : mother of 2 young children admitted w surgical mass scheduled for cerv lam in am. has weakness, atazia and 5/10 pain.

Plan Priorities; npo til surgery, help pt identify & contact family member re: assisting post discharge , assess pain control w/ parental meds

It is the beginning of the next Shift……

  1. Review the pathway and the phase. Are any changes needed? NO
  2. Document expected short term goals for your shift. Be realistic. If it is night shift, you would not want to put SW consult as a goal but adding a goal for “x” of hours of uninterrupted sleep would be appropriate. Could you put in as a goal for night shift to obtain order for SW consult? YES

Acute Pain : pain less than 4/10 w/ Morphine and positioning.

Fear: identifies family members willing to assist with care post op and post discharge. Verbalizes fears.

Injury risk other: will not fall

It is the end of your shift.

Mary Lou has received adequate pain control and reported pain scores of 4 or less all shift. She has not fallen. Her parents are driving in from out of town to help with her care and to take care of the children. She verbalized increased fears re: nature of the mass and required Ativan to assist with anxiety and fear in order to sleep. She is scheduled for 10 am surgery and has yet to sign her consent or have anesthesia consult.

  1. Document on the short term goal outcomes as well as a Nursing Summary and plan priorities for the next shift.

Acute Pain : Met

Fear: improved , unchanged or deteriorating are all possibilities depends on how the learner sees it.

Injury risk other: met

Nursing Summary: should include that parents will help with care of pt and children; increased anxiety and needed ativan to sleep

Plan priorities: Complete prep for OR- sign consent, anesthia to see pt.

Mary Lou is 3 days post op and being discharged. The neck mass was benign and her fear problem is resolved but she is still requiring Lortab to manage her pain. The surgeons have said she should be able to transition to Motrin for pain in 7-10 days.

8. Document on her outstanding problem and discharge plans.

Your pain problems needs to be addressed but it is NOT met yet.

Other considerations:

  1. On day shift, you are very focused on helping a patient increase activity tolerance and have ambulation goals. On night shift, there is a real priority for the patient to get adequate rest and sleep so that he is able to fully participate in therapy during the day.
  2. Should day shift inactivate night shift goal that is NOT a priority for them? (No) Does day shift have to document against a night shift-specific goal? (No)
  3. Should night shift inactivate day-shift specific goals? (No)
  4. Nurse Florence documented Alteration in Breathing Pattern as a priority problem for a pt. with COPD. Nurse Clara ended that problem and started a new priority problem Alteration in Gas Exchange. The next day Nurse Florence ended that problem and restarted Alteration in Breathing Pattern. What’s wrong with this picture?