Patient Scenario
C.T., a 73-year-old male, is admitted to your surgical unit following a bowel resection. He has a central line, a Foley catheter, and is NPO with IV fluids. Current orders:
- Lactated Ringer’s at 125 mL/hr
- Daily weights
- Strict I&O
- BMP q6h
- Ondansetron IV q6h PRN
- IV Morphine q4h PRN
- Foley catheter to gravity drainage
- Oxygen per protocol
1. Are these initial orders appropriate for C.T.? Why or why not?
Progress Note #1
At 1600, the UAP reports:
- BP: 96/58
- HR: 108
- RR: 20
- Temp: 98.2°F
- SpO2: 95%
- Foley output: 40 mL over last 3 hours
2. What concerns you based on these findings?
[Select All That Apply]
3. What assessments are most relevant now for C.T.?
[Radio Button Grid]
| Assessment Task | Relevant Now | Possibly Relevant | Not Relevant |
|---|---|---|---|
| Capillary refill | |||
| Orthostatic BP | |||
| Bowel sounds | |||
| Weight trend | |||
| EKG |
4. Bowtie: Suspected Condition = Hypovolemia
Supporting Findings (2)
Suspected Condition (1)
Nursing Interventions (2)
↓ Urine output
Hypovolemia
Low blood pressure
Notify provider for possible fluid bolus
Trend intake/output and weight
Administer diuretics
Increase potassium infusion
5. Fill in the Blanks
Post-operative patients are at risk for because of . Additional factors include , which can .
6. What’s your nursing priority?
[Multiple Choice]
7. Which interventions will you initiate?
[Select 6]
8. What can you delegate to the UAP?
[Select all that apply]
9. Which are SMART goals?
[Select all that apply]
Progress Note #2
At 1830, new vitals:
- BP: 110/64
- HR: 88
- UOP: now 100 mL over 3 hours
10. Has C.T.’s condition improved? Provide rationale.
[Yes/No with explanation]
11. SBAR Practice
[Radio Matrix]
| Item | S (Situation) | B (Background) | A (Assessment) | R (Recommendation) |
|---|---|---|---|---|
| “BP dropped to 96/58 with HR 108, UOP 40 mL/3hr” | ||||
| “Status post bowel resection, NPO, on IV fluids” | ||||
| “Suspect hypovolemia with possible pre-renal AKI” | ||||
| “Recommend fluid bolus and labs if trend continues” |
12. Lab results: BUN 29, Creatinine 1.7. Do you change the plan?
[Multiple Choice]