PRACTICE SCENARIO
You are working day shift and your 27 yo ,Mary Lou was admitted to the Ortho unit around 5pm
after an MRI revealed a cervical cord mass. She is experiencing weakness, is ataxic and has neck
and back pain. Her pain score is a 5 with morphine on board. She is scheduled for a cervical
laminectomy tomorrow. She is a single mother and concerned about her 4 and 2 year old children
and how she will care for them after surgery.
1. Select and Save Pathway ( StarPanel)
Cervical Surgery (Ortho)
To select a training census and patient.
2. Document Pathway Name & Phase (HED)
REMEMBER TO USE HED TRAIN
Notice that the cervical surgery pathway does not have a preop phase so pick the best fit
– Day of Surgery since the pt is going for surgery tomorrow.
Cervical Surgery (Ortho)
Phase: Day of surgery
3. Create 2-3 Priority Problems (HED) and Define Expected outcomes (long term
goals) for each problem
Pain
Acute pain related to neck mass
Expected outcome: improved
Self Concept
Feat related to neck mass biopsy and care of children post op
Expected outcome: improve
Safety
Injury Risk Other related to ataxia and narcotics for pain; potential to fall
Expected outcome: improved
4. Enter a Nursing Summary and Plan Priorities for the next shift since it is almost
shift change time.
Summary : mother of 2 young children admitted w surgical mass scheduled for
cerv lam in am. has weakness, atazia and 5/10 pain.
Plan Priorities; npo til surgery, help pt identify & contact family member re:
assisting post discharge , assess pain control w/ parental meds
It is the beginning of the next Shift……
5. Review the pathway and the phase. Are any changes needed? NO
6. Document expected short term goals for your shift.
Be realistic. If it is night
shift, you would not want to put SW consult as a goal but adding a goal for “x” of
hours of uninterrupted sleep would be appropriate. Could you put in as a goal
for night shift to obtain order for SW consult? YES
Acute Pain : pain less than 4/10 w/ Morphine and positioning.
Fear : identifies family members willing to assist with care post op and post
discharge. Verbalizes fears.
Injury risk other: will not fall
It is the end of your shift.
Mary Lou has received adequate pain control and reported pain scores of 4 or less all shift. She
has not fallen. Her parents are driving in from out of town to help with her care and to take care
of the children. She verbalized increased fears re: nature of the mass and required Ativan to
assist with anxiety and fear in order to sleep. She is scheduled for 10 am surgery and has yet to
sign her consent or have anesthesia consult.
7. Document on the short term goal outcomes as well as a Nursing Summary and
plan priorities for the next shift.
Acute Pain : Met
Fear : improved , unchanged or deteriorating are all possibilities depends on how the
learner sees it.
Injury risk other: met
Nursing Summary: should include that parents will help with care of pt and children;
increased anxiety and needed ativan to sleep
Plan priorities: Complete prep for OR- sign consent, anesthia to see pt.
Mary Lou is 3 days post op and being discharged. The neck mass was benign and her fear
problem is resolved but she is still requiring Lortab to manage her pain. The surgeons have said
she should be able to transition to Motrin for pain in 7-10 days.
8. Document on her outstanding problem and discharge plans.
Your pain problems needs to be addressed but it is NOT met yet.
Other considerations:
1. On day shift, you are very focused on helping a patient increase activity tolerance and
have ambulation goals. On night shift, there is a real priority for the patient to get
adequate rest and sleep so that he is able to fully participate in therapy during the day.
a. Should day shift inactivate night shift goal that is NOT a priority for them? (No)
Does day shift have to document against a night shift-specific goal? (No)
b. Should night shift inactivate day-shift specific goals? (No)
c. Nurse Florence documented Alteration in Breathing Pattern as a priority problem for
a pt. with COPD. Nurse Clara ended that problem and started a new priority
problem Alteration in Gas Exchange. The next day Nurse Florence ended that
problem and restarted Alteration in Breathing Pattern. What’s wrong with this
picture?