Best Nursing Decisions Discussion

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Best Nursing Decisions Discussion

Best Nursing Decisions Discussion

Scenario
You finished new graduate orientation yesterday on a general medical surgical unit, and today you will independently care for two clients. As you receive a report on the second client at 0730, your Preceptor stops by to ask how the first day by yourself is coming along and reminds you to complete the final items on your training list today before the end of the 12-hour shift.

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Complete the new online training model and quiz on the sliding insulin scale
Complete the orientation evaluation form
Sign up for one of the four nursing committees
Complete and sign the orientation reflection journal
Attend the new employee luncheon from 1-2 pm sponsored by the hospital physicians
Client 1

Client 2

25 year old female 24 hours post-op from a Roux-en-Y gastric bypass
BMI of 50
History of hypertension and sleep apnea
No complications post-operative
Pain at 4 am, three on a scale of 10
Nasogastric tube to gravity
NPOMother stayed overnight but left early this morning to shower and will return later in the afternoon
Waiting on morning labs
46 year old male admitted 72 hours prior with severe GERD and difficulty swallowing
History of alcoholism, hypertension
Smoked two packs per day for 22 years
Endoscopy for Barrett’s Esophagus was negative on the day of admission
Pain at 4 am, two on a scale of 10
Due to resume clear liquid diet this morning
Potential discharge later today home with family
The ex-wife has stayed in a room with a client and has been disruptive at times demanding pain medication and food.
Waiting on morning labs
Physician orders:

Dietary Consult
Bariatric Behavioral Therapist Consult
0.45% NS intravenous infusion post op
Medications:

Protonix 40 mg once daily, intravenous infusion
Switch to oral Protonix 40mg day of discharge
IV infusion 0.9% NS 50 ml/hour
Resume 50mg Lopressor (metoprolol) PO twice daily after rule out Barrett’s Esophagus
1-2mg Morphine Sulfate IV PRN q 4-6 hours for pain greater than 6 out of 10
TIME

EVENT

0800

You prioritize the need to assess the 46 year old male first since he has 0900 medications and the physician is rounding and should order discharge today. Assessment and vital signs reveal no concerns, ex-wife not present. A physician writes an order to discharge this client today. The client asks you to return in 30 minutes and go over discharge when ex-wife is present to hear instructions. You administer Lopressor and Protonix.

0830

You assess the 25 year old post bariatric surgery client. Vital signs and morning labs are within acceptable limits, and client reports pain two on a scale of 10. While assessing for bowel sounds, you notice the nasogastric (NG) tube not secured to the nose, and the client reports the tube partially came out when she blew her nose but she was able to push it back in with no pain. You document NG tube in place and assist the client to the bathroom.

0900

You return to 46 year old client and review discharge instructions with the client and ex-wife, discontinue the IV infusion, remove the intravenous catheter, and complete discharge summary.

0945

Transport stops by to take 25 year old client to meet with a support group for bariatric surgery clients — you okay transport.

1000

Physician stops into see a bariatric client and is upset you let her leave for support group before rounding. You report no concerns, physician reviews chart and writes discharge order for later in the afternoon if no vomiting or pain. The NG tube can be removed at noon by the Nurse Practitioner, and a diet of clear liquids resumed at 6 pm if no vomiting or gastric distention. Call immediately if any vomiting or signs of gastric distention occur.

1030

You take a break to complete orientation reflection journal, orientation evaluation, and online sliding insulin scale training module and quiz.

1130

The 25 year old bariatric client returns from the support group, you see her ambulating in the hallway, and you notice the NG tube is missing. The client states the tube fell out of her nose when she stood up to introduce herself. She has no complaints of nausea and no evidence of gastric distention. You document the NG tube was removed accidentally by the client.

1200

46 year old male client calls and expresses frustration at a time to discharge. He wants to be home by 3 pm for his son’s birthday party. You call transport who assures you and the client they will arrive before 1 pm to discharge the client.

1215

Morning documentation complete, all orders are in the system, and both clients are stable. You are amazed at how smooth the first day is going. You head to the new employee luncheon with your Preceptor.

1330

You return from lunch and find the 46 year old client discharged, and you must prepare for a new admit from the emergency room with rule out pancreatitis. You feel apprehension since this will be your first admit, so you reach out to your Preceptor to review policy and procedure for new admissions.

Best Nursing Decisions Discussion

Best Nursing Decisions Discussion

1345

While working with your Preceptor, the Certified Nursing Assistant stops by and reports the 25 year old client refused an afternoon visit from a member of the bariatric support group, complaining of fatigue. Her noon vital signs were blood pressure 90/40, heart rate 112, and respiratory rate 28. Your Preceptor assures you these vital signs, and fatigue often occurs with this type of client. She susgest, the client is probably depressed, ready to go home, and suggests to let her rest for the afternoon.

1415

The new admit from the emergency department arrives with two pages of physician orders and a communication challenge since he speaks and understands only Spanish. He has pain in the abdomen and begins vomiting. Seeing you are now very busy, the Preceptor offers to “look in” on your 25 year old client and will take care of any concerns. Also, she will order a translator to assist with the new admit, while you focus on taking care of the physician orders.

1730

Finally, all orders for the new admit are in the system; pain decreased, no further vomiting, and he is resting comfortably. While waiting for lab results, you decide to check on the 25 year old client.

1745

On the way to the client’s room, the Nurse Manager stops and asks you to take a moment to fill out a volunteer form for one of the four nursing committees on the Unit.

1815

You return to the 25 year old client’s room and find her unresponsive, pale, with no heart beat or respirations. The abdomen is distended and hard. Attempts are made for resuscitation but are not successful. The client is deceased.

1900

You prepare to leave to go home. The Nurse Manger stops you and asks to debrief the situation. After reviewing the chart and discussing the situation, she is concerned and sees errors in your judgement and actions. She is sure the client’s death will be a sentinel event and warrant a review by the Internal Review Board.

Instructions
To prepare for debriefing with the Internal Review Board, the Nurse Manager asks you to submit an internal memo with your analysis and perceptions of the events that occurred, including:

Description of the errors that occurred
Support choices with rationales
Description of why the errors occurred
Support choices with rationales
Strategies for appropriate actions to avoid errors identified
Support strategies with rationales, nursing theory and evidence from the literature
Ideas stated with professional language and attribution for credible sources with correct APA citation, spelling, and grammar
Resources
NCSBN Nursing Clinical Judgment Model

Assessing Higher-Order Cognitive Constructs by Using an Information Processing Framework

Click here for a Library and Learning Services page on Memos in the Writing Guide.

Click here for a Library and Learning Services page on composing a Memo.

Click here for a Library and Learning Services APA Guide.

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Best Nursing Decisions Discussion

Best Nursing Decisions Discussion

You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.

Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.

Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.

The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.

ADDITIONAL INSTRUCTIONS FOR THE CLASS

Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality

Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes

I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
It is best to paraphrase content and cite your source.
LopesWrite Policy

For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
Late Policy

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.
As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication

Communication is so very important. There are multiple ways to communicate with me:
Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

 

 

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