MED-SURG SCORE: 100 TIME ELAPSED: 1:17 PAUSE
Glenn Massey Room 301
Glenn Massey, ,post 2nd and 3rd degree burns on 18% of his body. Burns are located on his arms
and upper torso. The patient works at a chemical refinery; this was an occupational injury after an
explosion at the plant. You receive the following report from the trauma burn ICU nurse, “Situation
is Glenn Massey is now stable to be transferred to the floor. Background is patient was admitted 7
days ago after an occupation injury resulting in burns to 18% of his body. Patient arrived via
ambulance in critical condition and was intubated upon arrival. The assessment is vital signs are
BP: 142/91, T: 99.4 F, 37.4 C, P: 102, R: 28, PaO2: 96% on room air. Patient is AAO x4. He is
receiving 5mg Morphine IV q3 hours PRN for pain control. IV at 150 mL/hr D5 ½ NS to a right
subclavian. Foley catheter is draining clear urine, I&O in chart. Patient requires dressing changes
every shift. Recommendation is patient is ready to be transferred to the floor, and will need strict
wound isolation. Family has been notified of his transfer, and patient believes he can return to work
in a few days.”
You responded correctly to 6 out of 6 evaluations:
Category Your response Explanation
Educational Needs ! Increased acuity Needs burn care education
Fall risk ! Increased acuity Patient has IV, foley catheter, and is receiving narcotics.
Health change ! Increased acuity Patient has significant burns to the upper body.
Pain level ! Increased acuity Due to 2nd degree burns. 3rd degree burns typically do not indicate pain as nerve endings have been destroyed.
Psychological Needs ! Normal acuity No indication of increased need
Neurological ! Normal acuity Patient is AAO x4
Continue...
, MED-SURG SCORE: 100 TIME ELAPSED: 3:06 PAUSE
Lithia Monson Room 302
Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma. Hx of dementia, from nursing home, fall one day ago. No known
allergies (NKA). Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. Neuro- confusion to time and place, but oriented to self,
speech clear, poor historian, did not recognize son today which is new for her; Neuro assessment and vital signs q1 hr. Skin warm
dry, bruises on forehead with small laceration. Increased fall risk. DSD (dry sterile dressing), forehead laceration clean and dry intact.
20ga. Hep-Lock in place left AC. GI WNL. Cardiovascular has pacer with rate of 82bpm on demand. Strict I&O, regular diet, intake
50%. Waist belt restraint PRN; family sitter at bedside, assist with bath. Dr. Altace
You responded correctly to 6 out of 6 evaluations:
Category Your response Explanation
Educational Needs ! Increased Status assessment reports head injury, Dementia, confusion, recent fall, poor intake, and assistance with bath.
acuity
Fall Risk ! Increased Status assessment reports head injury, Dementia, fall one day ago, confusion to time/ place, family sitter, and
acuity assistance with bath.
Health Change ! Increased Status assessment reports head injury- r/o subdural hematoma, recent fall, Confusion, strict I&O, intake 50%.
acuity
Pain Level ! Normal acuity No indication of pain
Psychological ! Increased Status assessment reports history of dementia, confusion- time/place, poor historian, didn't recognize son.
Needs acuity
Sensorium ! Increased Status assessment reports head injury, Dementia, fall x 1 day, confusion- time/place, didn't recognize son, neuro
acuity assessment q1 hr.
Continue...
, MED-SURG SCORE: 100 TIME ELAPSED: 4:05 PAUSE
Mary Barkley Room 303
Mary Barkley, 74y/o female has been admitted to your floor with a respiratory infection and she has tested positive for COVID19. She
resides in an assisted living facility which has seen four deaths related to COVID19. She is exhibiting the same initial signs and
symptoms as the other patients and her primary care provider would like to start aggressively treating her. She is running a low-
grade fever 99.8 and has a sore scratchy throat which is causing an unproductive cough. She also is complaining of chills, muscle
pain and headache. She is an at-risk patient because of her age. She also suffers from Lupus and is already taking
Hydroxychloroquine, a first-line lupus therapy, but there is no conclusive evidence of its benefits for coronavirus yet. She is very
fearful and is requesting to see her family. She states that she does not want to die alone.
You responded correctly to 6 out of 6 evaluations:
Category Your response Explanation
Educational Needs ! Increased acuity Patient needs to understand the need for isolation precautions as a result of COVID-19.
Fall Risk ! Normal acuity No indication of unstable gait at this time.
Health change ! Increased acuity Tested positive for COVID-19 with respiratory symptoms.
Neurological ! Normal acuity No indication of deficit at this time.
Pain level ! Increased acuity Normal, rationale: Patient states the pain has subsided
Psychological Needs ! Increased acuity Fearing loneliness, isolation, and possible death.
Continue...
, MED-SURG SCORE: 100 TIME ELAPSED: 4:42 PAUSE
Ramona Stukes Room 304
Ramona Stukes, 69 yr-old, third day post-op cholecystectomy. Non-significant past medical history. No known allergies (NKA). Vital
signs -Temp 98.6, BP 114/62, P 100, RR 20, SaO2 94%. Neuro WNL, alert, and cooperative. Skin warm and dry, daily dressing
changes, T-tube without drainage. NG tube to low suction possibly D/C'd today after Dr. Levine rounds. Today's incentive spirometry
Tidal Volume is 1250ml, improvement over yesterday's 900ml. NPO with small amount of ice chips only. Today's weight 226. IV D5
1/2 NS with 20 KCL @ 125 ml/hr in left forearm. Last pain medicine 2hrs ago at 1300(Demerol 50mg/ Zofran 4mg IV). Ambulates with
assistance. Dr. Levine
You responded correctly to 6 out of 6 evaluations:
Category Your response Explanation
Educational ! Increased Status assessment reports NG tube possibly D/C'd, NPO with ice chips only.
Needs acuity
Fall Risk ! Increased Status assessment reports NG tube, Today's weight 226, IV left forearm, Pain medicine 2hrs ago at 1300, Ambulates with
acuity assistance.
Health Change ! Increased Status assessment reports patient is 3rd day post-op resection. NG tube possibly D/C'd. Today's incentive spirometry Tidal
acuity Volume is 1250ml…, NPO.
Pain Level ! Increased Patient is receiving Demerol for pain
acuity
Psychological ! Normal Status assessment reports indication of increased psychological acuity
Needs acuity
Sensorium ! Normal Status assessment reports no indication of increased LOC acuity
acuity
Continue...
Glenn Massey Room 301
Glenn Massey, ,post 2nd and 3rd degree burns on 18% of his body. Burns are located on his arms
and upper torso. The patient works at a chemical refinery; this was an occupational injury after an
explosion at the plant. You receive the following report from the trauma burn ICU nurse, “Situation
is Glenn Massey is now stable to be transferred to the floor. Background is patient was admitted 7
days ago after an occupation injury resulting in burns to 18% of his body. Patient arrived via
ambulance in critical condition and was intubated upon arrival. The assessment is vital signs are
BP: 142/91, T: 99.4 F, 37.4 C, P: 102, R: 28, PaO2: 96% on room air. Patient is AAO x4. He is
receiving 5mg Morphine IV q3 hours PRN for pain control. IV at 150 mL/hr D5 ½ NS to a right
subclavian. Foley catheter is draining clear urine, I&O in chart. Patient requires dressing changes
every shift. Recommendation is patient is ready to be transferred to the floor, and will need strict
wound isolation. Family has been notified of his transfer, and patient believes he can return to work
in a few days.”
You responded correctly to 6 out of 6 evaluations:
Category Your response Explanation
Educational Needs ! Increased acuity Needs burn care education
Fall risk ! Increased acuity Patient has IV, foley catheter, and is receiving narcotics.
Health change ! Increased acuity Patient has significant burns to the upper body.
Pain level ! Increased acuity Due to 2nd degree burns. 3rd degree burns typically do not indicate pain as nerve endings have been destroyed.
Psychological Needs ! Normal acuity No indication of increased need
Neurological ! Normal acuity Patient is AAO x4
Continue...
, MED-SURG SCORE: 100 TIME ELAPSED: 3:06 PAUSE
Lithia Monson Room 302
Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma. Hx of dementia, from nursing home, fall one day ago. No known
allergies (NKA). Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. Neuro- confusion to time and place, but oriented to self,
speech clear, poor historian, did not recognize son today which is new for her; Neuro assessment and vital signs q1 hr. Skin warm
dry, bruises on forehead with small laceration. Increased fall risk. DSD (dry sterile dressing), forehead laceration clean and dry intact.
20ga. Hep-Lock in place left AC. GI WNL. Cardiovascular has pacer with rate of 82bpm on demand. Strict I&O, regular diet, intake
50%. Waist belt restraint PRN; family sitter at bedside, assist with bath. Dr. Altace
You responded correctly to 6 out of 6 evaluations:
Category Your response Explanation
Educational Needs ! Increased Status assessment reports head injury, Dementia, confusion, recent fall, poor intake, and assistance with bath.
acuity
Fall Risk ! Increased Status assessment reports head injury, Dementia, fall one day ago, confusion to time/ place, family sitter, and
acuity assistance with bath.
Health Change ! Increased Status assessment reports head injury- r/o subdural hematoma, recent fall, Confusion, strict I&O, intake 50%.
acuity
Pain Level ! Normal acuity No indication of pain
Psychological ! Increased Status assessment reports history of dementia, confusion- time/place, poor historian, didn't recognize son.
Needs acuity
Sensorium ! Increased Status assessment reports head injury, Dementia, fall x 1 day, confusion- time/place, didn't recognize son, neuro
acuity assessment q1 hr.
Continue...
, MED-SURG SCORE: 100 TIME ELAPSED: 4:05 PAUSE
Mary Barkley Room 303
Mary Barkley, 74y/o female has been admitted to your floor with a respiratory infection and she has tested positive for COVID19. She
resides in an assisted living facility which has seen four deaths related to COVID19. She is exhibiting the same initial signs and
symptoms as the other patients and her primary care provider would like to start aggressively treating her. She is running a low-
grade fever 99.8 and has a sore scratchy throat which is causing an unproductive cough. She also is complaining of chills, muscle
pain and headache. She is an at-risk patient because of her age. She also suffers from Lupus and is already taking
Hydroxychloroquine, a first-line lupus therapy, but there is no conclusive evidence of its benefits for coronavirus yet. She is very
fearful and is requesting to see her family. She states that she does not want to die alone.
You responded correctly to 6 out of 6 evaluations:
Category Your response Explanation
Educational Needs ! Increased acuity Patient needs to understand the need for isolation precautions as a result of COVID-19.
Fall Risk ! Normal acuity No indication of unstable gait at this time.
Health change ! Increased acuity Tested positive for COVID-19 with respiratory symptoms.
Neurological ! Normal acuity No indication of deficit at this time.
Pain level ! Increased acuity Normal, rationale: Patient states the pain has subsided
Psychological Needs ! Increased acuity Fearing loneliness, isolation, and possible death.
Continue...
, MED-SURG SCORE: 100 TIME ELAPSED: 4:42 PAUSE
Ramona Stukes Room 304
Ramona Stukes, 69 yr-old, third day post-op cholecystectomy. Non-significant past medical history. No known allergies (NKA). Vital
signs -Temp 98.6, BP 114/62, P 100, RR 20, SaO2 94%. Neuro WNL, alert, and cooperative. Skin warm and dry, daily dressing
changes, T-tube without drainage. NG tube to low suction possibly D/C'd today after Dr. Levine rounds. Today's incentive spirometry
Tidal Volume is 1250ml, improvement over yesterday's 900ml. NPO with small amount of ice chips only. Today's weight 226. IV D5
1/2 NS with 20 KCL @ 125 ml/hr in left forearm. Last pain medicine 2hrs ago at 1300(Demerol 50mg/ Zofran 4mg IV). Ambulates with
assistance. Dr. Levine
You responded correctly to 6 out of 6 evaluations:
Category Your response Explanation
Educational ! Increased Status assessment reports NG tube possibly D/C'd, NPO with ice chips only.
Needs acuity
Fall Risk ! Increased Status assessment reports NG tube, Today's weight 226, IV left forearm, Pain medicine 2hrs ago at 1300, Ambulates with
acuity assistance.
Health Change ! Increased Status assessment reports patient is 3rd day post-op resection. NG tube possibly D/C'd. Today's incentive spirometry Tidal
acuity Volume is 1250ml…, NPO.
Pain Level ! Increased Patient is receiving Demerol for pain
acuity
Psychological ! Normal Status assessment reports indication of increased psychological acuity
Needs acuity
Sensorium ! Normal Status assessment reports no indication of increased LOC acuity
acuity
Continue...
