Week 6
Simulation Laboratory Activities Day 4
Nursing Handover
Ruby had an uneventful night, sleeping for long periods. Ruby continues to use the PCA when she gets pain. Ruby’s pain score is 4/10 when laying in bed still but when she has to go to the toilet or move around the pain in the knee is 7-8/10. There is minimal blood loss from the wound drain.
Dr. Alverez (surgeon) has come to review Ruby’s wound and has noted in the progress notes that the wound is slightly sloughy requiring a daily irrigation dressing.
Lab Activities
It is now 0800hrs you are the RN assigned to care for Ruby. When you enter Ruby’s room you notice that she is in the supine position, pale and responsive.
Observations:
- HR: 88 bpm
- RR: 24 rpm
- SpO2: 93% on room air
- BP: 102/58
- TEMP: 36.7 degrees Celsius
Questions to consider?
- What is the most likely cause of Ruby’s current condition?
- What action is required by you?
- Is this a medical emergency?
The activities for this lab are:
- Nursing assessment
- Respiratory assessment
- Irrigation wound dressing
- Change the PCA as per orders and attend to PCA observations
- Write nursing report
- Update Multidisciplinary Careplan (MDCP)
