Annual Revalidation Case Study for Adult Ambulatory Areas

Mr. James, a 55 year old patient, and his wife are being seen in the

clinic.

As you are talking with his wife you notice that she has sneezed a couple of times and has been coughing. What respiratory hygiene/cough etiquette education should you provide?

a. Instruct the wife that she must leave the facility.b. Provide tissues to the wife and educate

regarding covering nose/mouth with tissue, disposing of tissue and then performing hand hygiene.

c. Consider having the wife wear a mask if the coughing and/or sneezing become worse .

d. Both B and C.

As part of orienting Mr. James and his wife to the clinic and exam

room, you educate them on clinic policies.

What key patient/family education should you share regarding hand hygiene?

a. Patient/family should only wash their hands when visibly soiled.

b. Family should perform hand hygiene using both soap and water as well as alcohol foam before entering patient room.

c. If patient is on contact isolation for C-Diff, family should perform hand hygiene only with alcohol foam when leaving the patient’s room.

d. Family should perform hand hygiene before any patient contact (e.g., before entering room, before/after assisting patient with ADLs, etc.).

*New Slide*

You get Mr. James settled into his exam room, take his vital signs and review his allergies

and current medications.

*New Slide*

When taking Mr. James’ blood pressure, you know that it is important to a. Use any adult size blood pressure cuffb. Use a large size adult blood pressure cuff forincreased accuracyc. Use a blood pressure cuff that covers 80% of the

circumference of the upper armd. Use a pediatric size blood pressure cuff if it is the only cuff available

Mr. James’ vital signs are as follows:• Temp – 39.5C

• HR – 82• RR – 18

• BP – 132/80

You assess the fever further and decide that he may need something to help bring the fever

down. You give report to the provider, inform them about the fever and ask for an order.

*Revised Slide*

Because the patient has difficulty swallowing tablets the provider enters an order for: Acetaminophen 650mg PO for

fever x 1 now for temp > 38.5C

You obtain a new bottle of Tylenol and label it appropriately after drawing up the

dose.

Tylenol Picture – drop and drag

You are assessing Mr. James’ pain. Which pain scale should you use? (Click on the best response)

Assessment Sedation Normal Pain / Agitation Criteria - 2 - 1 0 1 2

Crying I rritability

No cry with painful stimuli

Moans or cries minimally with painful stimuli

Appropriate crying Not irritable

Irritable or crying at intervals Consolable

High-pitched or silent-continuous cry Inconsolable

Behavior State

No arousal to any stimuli No spontaneous movement

Arouses minimally to stimuli

Little spontaneous movement

Appropriate for gestational age

Restless, squirming Awakens frequently

Arching, kicking Constantly awake or Arouses minimally / no movement (not sedated)

Facial Expression

Mouth is lax No expression

Minimal expression with stimuli

Relaxed Appropriate

Any pain expression intermittent

Any pain expression continual

Extremities Tone

No grasp reflex Flaccid tone

Weak grasp reflex

muscle tone

Relaxed hands and feet Normal tone

Intermittent clenched toes, fists or finger splay Body is not tense

Continual clenched toes, fists, or finger splay Body is tense

Vital Signs HR, RR, BP, SaO2

No variability with stimuli Hypoventilation or apnea

< 10% variability from baseline with stimuli

Within baseline or normal for gestational age

10-20% from baseline SaO2 76-85% with stimulation – quick recovery

> 20% from baseline SaO2 75% with stimulation – slow recovery Out of sync with vent

0 1 2 3 4 5 6 7 8 9 10No Pain

Worst Pain

Categories 0 1 2Face No

particular expression or smile

Occasional grimace or frown, withdrawn, disinterest

Frequent to constant frown, quivering chin, clenched jaw

Legs Normal position or relaxed

Uneasy, restless, tense Kicking or legs drawn up

Activity Lying quietly, normal position, moves easily

Squirming, shifting back and forth, tense

Arched, rigid, or jerking

Cry No cry (awake or asleep)

Moans or whimper; occasional complaint

Crying steadily, screams, or sobs, frequent complaints

Consoliability Content, relaxed

Reassured by occasional touching, hugging, or being talked to; distractible

Difficult to console or comfort

After assessment of Mr. James pain, the provider orders a dose of Morphine.

How do you determine if this is a high alert medication?

a. You note the medication label which identifies the medication as high alert.

b. Your check the MAR which will indicate special process for high alert medication.

c. You recall that any medication given as an IV infusion is considered High Alert.

d. You refer to the list of medications in the Nursing Process Standard “High Alert Medications Protocol” and the high alert drug list from pharmacy.

If it was Influenza season and Mr. James had an order for the Influenza Vaccine while in clinic, you would administer the vaccine a. Subcutaneous, using a 180 degree angle in the

deltoid b. Intramuscular, using a 90 degree angle in the vastus

lateralisc. Subcutaneous, using a 90 degree angle in the vastus

lateralisd. Intramuscular, using a 90 degree angle in the

deltoid

The provider tells you that he has now ordered a CXR and that the patient must go to radiology. You now have orders for Mr. James

to have completed before he goes down to radiology.

Zofran 8 mg IV for nausea x 1 now

You prepare the Zofran in a syringe to give to Mr. James. What information must be included on the

syringe that contains the medication?choose all that apply

One of the 6 Rights of Medication Administration is to verify the right patient.

How do we verify Right Patient in the ambulatory setting?

a. Name and history numberb. Name and addressc. Name and room number d. Name and date of birth

A Transporter has just arrived to take Mr.

James down to X-ray. You have completed the “Ticket to Ride”.

Mr. James arrives for his procedure. The staff performs a time-out. Which of the following statements about time-out are correct? Choose all that apply

a. Only the transporter and the receiving nurse perform the time-out.

b. All members of the procedure team perform the time-out.c. The right patient is verified.d. The right procedure is verified.e. The pre-procedure check-list is completed.f. Documentation by the proceduralist that time-out occurred

is included in the medical record.g. Time-out is not required for this procedure.

*New Slide*Mr. James has returned to clinic after his X-ray. You need to reassess his fever now that it has been over an hour since he received the dose of Tylenol ordered in clinic. You are busy with another sick patient in clinic and think about asking your co-worker to re-check Mr. James vital signs. Which of the following statements regarding delegation is true?

a. An unlicensed assistive personnel (i.e.. CMA, NCA) can delegate to another unlicensed assistive personnel.

b. A Registered Nurse can delegate any task to a CMA or NCA. c. An RN can delegate to a CMA or NCA only if the task is consistent with the

rules for delegation and the UAP is properly trained and competent. d. A CMA or NCA can not refuse a task that is delegated by an RN.

Mr. James is seen by the provider and given all of his test results. His fever

and nausea have resolved. You provide final patient education to Mr.

James and his wife.

*Revised Slide*

*New Slide*

In providing patient education to Mr. James and his wife you review with him his new prescriptions and home care instructions the doctor has ordered. In assuring that Mr. James understands the patient education you have provided, you know to a. Ask Mr. James to repeat back to you the instructions you

have given himb. Provide the number for the telephone triage line and on call

physicianc. Ask Mr. James and his wife if they have any questions and

provide them with written directionsd. All of the above

As you wrap up your day you are able to see

how your actions throughout today reflect the DUHS

Professional Practice Model.

You advocated for your patient, collaborated with other disciplines

and provided safe care to your patients.