You are working as a nursing assistant at a hospital from 0700 to 1500 and have been assigned eight patients (10 rooms) on this med surg unit.
- All patients are full codes.
- All patients should have full VS (T,P,R,BP,POx,pain) at 0800 and 1200.
- All patients are scheduled for ROM TID unless otherwise specified.
- The primary language is English unless otherwise mentioned.
Create a chart and include the following:
- How will you prioritize your day hour by hour?
- What other information would you want to know?
- For what would you be particularly watching with each patient?
Room 100
Mr. Lopez (45yo) fell off a roof 3 days ago and has multiple contusions, abrasions. R leg fx, R arm fx, R shoulder rotator cuff injury, is on 4LNC, has an IV in his L forearm, and is in traction. He has a R chest tube for a pneumothorax. His primary language is Spanish. He is on CBR & is due for a CBB today. He eats a regular diet but needs assistance eating due to his injuries. He is right handed. He uses a bedpan. He is scheduled for AAROM on unaffected joints. The night CNA reported that he was acting confused last night.
Room 101
Mr. Thompson (33yo) was admitted to this unit from CCU yesterday. He has a h/o AMI (5 days ago), HTN, hyperlipidemia, and GAD. He is on 2LNC, has an IV in his R forearm, and a foley catheter. He is scheduled to get OOB and walk TID with 1-person assist. He is due for a shower this morning. His ordered diet is NAS, but his family is bringing in foods for him because he says he cannot eat the terrible food in the hospital. The night CNA reported that he was especially cranky last night and wants to sleep in this morning.
Room 102
Mr. Brown (28yo) had a CVA 5 days ago due to a sickle cell crisis. He is on 4LNC, has an IV in his L hand and has a condom catheter. He is on a regular diet but is having trouble feeding himself and has a referral to meet with OT regarding eating utensils that may help him to be more successful this afternoon. He is scheduled to get OOB and walk TID with a walker. He is HOH. The night CNA reported that he appeared to be in severe pain early in the shift and fell asleep at midnight and she didn't want to disturb him and didn't wake him up for VS at 0400. He is on a regular diet and can feed himself. He has a head MRI scheduled for 0715. He is due for a CBB this afternoon. The night CNA said he asked to speak with a pastor yesterday but they forgot to call and asked if you could call this morning. When you enter his room, he does not respond when you call his name.
Room 103
Mr. Chen (58yo) was admitted two days ago for severe dehydration due to N/V/D. His primary language is Mandarin Chinese. He has been having liquid diarrhea about 20 times/shift, is C. Diff positive, and is on contact precautions. He has an NGT and is NPO. He had an IV in his R hand, but the night CNA says that he accidentally pulled it out when he was trying to get to the BSC about 30 minutes ago and the nurse will need to put another one in this morning. The night CNA did not have time to change the bloody linens. He is scheduled for PROM TID. He has been hypotensive and bradycardic overnight and the nurse has asked that you get orthostatic VS ASAP.
Room 104
Mr. McMillan (89yo) was re-admitted at 0600. He had returned to the LTC facility where he lives but overnight developed SOB and changes in mental status. His highest temperature last night was 102.6F. He is on 60% FS and is ordered to TCDB Q2h. He was incontinent of urine and stool twice last night and the night CNA reports that he has a sacral pressure ulcer that he did not have when he was on the unit a week ago. He is on a mechanical soft diet and needs assistance with eating. He is on CBR.
Room 105
Mrs. Hamilton (66yo) was admitted 5 days ago s/p MVA. Her L leg was amputated due to a crushing injury. She has multiple abrasions and her L arm has an external fixator on it and her right hand is wrapped. She has a PICC in her right AC. She has been very sedated and is ordered for IS X 10 Q2hr. She had her NGT removed 2 days ago and was on a clear liquid diet yesterday with an order to advance as tol. She plans to try a full liquid diet today and needs assistance with eating. Her foley catheter was d/c'd yesterday and she uses the bedpan but has been incontinent several times. She is ordered OOB to chair TID with a 2-person assist. She has not had a BM for 2 days and is scheduled to get an enema this morning. Because she has multiple dressing changes, the CNA coordinates bath time with the RN. Her temperature at midnight was 100.3F. She has an order for a clean catch UA and C&S.
Room 106
Mrs. Smith (42yo) was admitted yesterday due to being unresponsive. She was dx with hyperglycemia and T2D. She is morbidly obese. She was on BR yesterday, but the physician ordered her to get OOB with a mechanical lift to the chair TID and to BSC prn starting today. Podiatry is coming later today to look at her feet because she has red places on a couple of her toes. She has been complaining of ear pain and throat pain of 7/10 overnight. Her foley catheter was removed at 0600 and someone is looking for a bariatric BSC to put in her room but has not found one yet. She is on an ADA 1800 cal diet and can feed herself. The CNA said Mrs. Smith just called out to say that she is having chills, needs to use the BSC, and is feeling really bad.
Room 107
This room is currently empty but the night CNA said she heard they were going to be admitting a patient to this room some time this morning but doesn't have any details.
Room 108
This room is currently empty.
Room 109
Ms. Davis (25yo) has a history of Cystic Fibrosis and major depression. She was admitted 3 days ago due to hemoptysis, tachypnea, and is positive for COVID - the special unit for COVID was full, so she was admitted to this overflow unit. She has high calorie shakes ordered between meals TID and is ordered extra salt and enzymes with meals. She has been complaining of severe fatigue and SOB and is on 4LNC. Her las pulse ox reading was 87% and the previous CNA said she forgot to mention that to the nurse. She refused her meals yesterday, saying she just felt too bad to eat. She asked yesterday if someone could cut her hair because it was getting in her way and was too heavy, but nobody had time to help her with that. She is scheduled for a CXR some time today.
