Patient Name: Lisa Rae
SIM Visit: Scenario #2
Hypotension and fall resulting in right hip
injury
Allergies: NKDA
DOB: November 24 Age 78
BSN – Foundation Lab Admission Ticket
Objectives: Performs safe patient care using DCN protocol (CO 4, 5, 8)
• Performs a head-to-toe assessment and recognizes normal and abnormal findings
(APPLYING) (CO 2, 7, 8)
• Designs an individualized nursing plan of care based on subjective/objective assessment
data (CREATING) (CO 2, 3, 5, 6, 7, 8)
• Performs safe oral medication administration (APPLYING) (CO 4, 7, 8)
•Uses therapeutic communication to actively engage patient and family in plan of care
(APPLYING) (CO 1, 2, 5, 7)
•Demonstrate teamwork and collaboration skills, including delegation
(APPLYING)(CO1, 4, 6, 7)
•Evaluates the patient’s responses to nursing interventions (EVALUATING) (CO 1, 3, 7, 8)
Review:
1. Basic environmental safety assessment and measures to maintain a safe environment
(SWIPE/BRowN COW)
2. Safe medication administration process according to the five rights.
3. How to do a head to toe assessment and use the Fall Assessment tool in your
Fundamentals book.
Complete the following questions prior to simulation for a patient that has fallen:
1. Describe 3 risk factors for falls in the elderly.
Home hazards, poor vision, and syncope are risk factors for falls in the elderly (Jarvis, 2020)
2. What is orthostatic hypotension?
Orthostatic hypotension is a sudden drop in blood pressure (over 10mm Hg in systolic
and over 10 mmHg in diastolic) (Jarvis, 2020).
3. What is osteoporosis?
Osteoporosis is a loss of mineralization bone mass disease that leads to porous bone and
an increase in fractures (Jarvis, 2020).
4. What patient population is of greatest risk for Osteoporosis?
Aging women are at greater risk of osteoporosis, but decreased levels of estrogen in either
sex can cause osteoporosis as well (Jarvis 2020)
5. What nursing interventions can be performed prior to providing patient with oxygen
therapy?
, Checking the Spo2 wave for accuracy, encourage deep breaths, inspect environment
(electrical equipment) and for at home care make sure there are no smokers (Potter &
Perry 2021).
6. What are the steps in pericare/catheter care?
Wash hands, use clean gloves, wipe front to back for female patients using a clean portion of
the washcloth with each wipe. Use soap or CHG if catheter is in place. For men, be sure to
wash around the urethral meatus and pull back foreskin if necessary. For all catheters use
CHG and hold the catheter near the urethral opening with one hand while using the other
had to clean the catheter without tugging or pulling. (Potter & Perry, 2021)
7. What patient education points can be offered for a patient who forgets to take their
medications?
Setting a timer/ reminder on their phone, using a calendar, purchasing a medication pill organizer
are ways to not forget to take your medication (Potter & Perry, 2021)
8. What does it mean to SBAR and include the assessments should be preform prior to
SBAR
SBAR is a communication tool used to effectively communicate critical information about a
patient among other healthcare providers. It stands for situation, background, assessment and
recommendation. Introduce and describe your location and role for caring for the patient then use
SBAR (Potter & Perry, 2021).
1. Using your Nursing Diagnosis Handbook list write 2 nursing diagnoses for a patient with
Hypotension and falls along with 3 nursing interventions and 3 patient educations for
each nursing diagnosis. (Use the Nursing Diagnosis Template below)
9. Med log: ** Pay attention to drug / drug interactions. What worries you about this
combination of medications? Use Med Log template below
1. Acetaminophen PO 2. Hydrochlorothiazide (HCTZ) PO 3. Dilaudid
(Hydromorphone) PO
Hydromorphone is used to control patients pain, however a side effect it has is hypotension. If
the patient is already on Hydrochlorothiazide which is an antihypertensive medication, it would
put the patient at risk for decreased cardiac output. This would cause a lack of perfusion to vital
organs in the body.
SIM Visit: Scenario #2
Hypotension and fall resulting in right hip
injury
Allergies: NKDA
DOB: November 24 Age 78
BSN – Foundation Lab Admission Ticket
Objectives: Performs safe patient care using DCN protocol (CO 4, 5, 8)
• Performs a head-to-toe assessment and recognizes normal and abnormal findings
(APPLYING) (CO 2, 7, 8)
• Designs an individualized nursing plan of care based on subjective/objective assessment
data (CREATING) (CO 2, 3, 5, 6, 7, 8)
• Performs safe oral medication administration (APPLYING) (CO 4, 7, 8)
•Uses therapeutic communication to actively engage patient and family in plan of care
(APPLYING) (CO 1, 2, 5, 7)
•Demonstrate teamwork and collaboration skills, including delegation
(APPLYING)(CO1, 4, 6, 7)
•Evaluates the patient’s responses to nursing interventions (EVALUATING) (CO 1, 3, 7, 8)
Review:
1. Basic environmental safety assessment and measures to maintain a safe environment
(SWIPE/BRowN COW)
2. Safe medication administration process according to the five rights.
3. How to do a head to toe assessment and use the Fall Assessment tool in your
Fundamentals book.
Complete the following questions prior to simulation for a patient that has fallen:
1. Describe 3 risk factors for falls in the elderly.
Home hazards, poor vision, and syncope are risk factors for falls in the elderly (Jarvis, 2020)
2. What is orthostatic hypotension?
Orthostatic hypotension is a sudden drop in blood pressure (over 10mm Hg in systolic
and over 10 mmHg in diastolic) (Jarvis, 2020).
3. What is osteoporosis?
Osteoporosis is a loss of mineralization bone mass disease that leads to porous bone and
an increase in fractures (Jarvis, 2020).
4. What patient population is of greatest risk for Osteoporosis?
Aging women are at greater risk of osteoporosis, but decreased levels of estrogen in either
sex can cause osteoporosis as well (Jarvis 2020)
5. What nursing interventions can be performed prior to providing patient with oxygen
therapy?
, Checking the Spo2 wave for accuracy, encourage deep breaths, inspect environment
(electrical equipment) and for at home care make sure there are no smokers (Potter &
Perry 2021).
6. What are the steps in pericare/catheter care?
Wash hands, use clean gloves, wipe front to back for female patients using a clean portion of
the washcloth with each wipe. Use soap or CHG if catheter is in place. For men, be sure to
wash around the urethral meatus and pull back foreskin if necessary. For all catheters use
CHG and hold the catheter near the urethral opening with one hand while using the other
had to clean the catheter without tugging or pulling. (Potter & Perry, 2021)
7. What patient education points can be offered for a patient who forgets to take their
medications?
Setting a timer/ reminder on their phone, using a calendar, purchasing a medication pill organizer
are ways to not forget to take your medication (Potter & Perry, 2021)
8. What does it mean to SBAR and include the assessments should be preform prior to
SBAR
SBAR is a communication tool used to effectively communicate critical information about a
patient among other healthcare providers. It stands for situation, background, assessment and
recommendation. Introduce and describe your location and role for caring for the patient then use
SBAR (Potter & Perry, 2021).
1. Using your Nursing Diagnosis Handbook list write 2 nursing diagnoses for a patient with
Hypotension and falls along with 3 nursing interventions and 3 patient educations for
each nursing diagnosis. (Use the Nursing Diagnosis Template below)
9. Med log: ** Pay attention to drug / drug interactions. What worries you about this
combination of medications? Use Med Log template below
1. Acetaminophen PO 2. Hydrochlorothiazide (HCTZ) PO 3. Dilaudid
(Hydromorphone) PO
Hydromorphone is used to control patients pain, however a side effect it has is hypotension. If
the patient is already on Hydrochlorothiazide which is an antihypertensive medication, it would
put the patient at risk for decreased cardiac output. This would cause a lack of perfusion to vital
organs in the body.
