Scenario...

I have never been so nervous in my entire life. I was scared stiff I wasn't going to pass.

Passing scenario is a requirement to stay in the nursing program. No pressure!

There were three parts to this scenario.

Part 1: Head to Toe assessment.
My patient was a 84 year old Caucasian female with pneumonia and dyspnea if she layed flat in bed. I took her vital signs and found out that her O2 saturation was at 82%. In case you don't know that is bad! A person should have their sats 90% or higher, but not to high because you can over oxygenate a person. Because I found out her O2 sats were 82% I administered O2 to her at a rate of 4 L/min. I then went on to do a focus assessment on her respiratory system. Upon completion I continued on with the Head to Toe assessment. I finally finished barely within the allotted time.

Part 2: Documentation
Now documenting seems easy right? WRONG! It is very hard to get the hang of. Everything needs to be documented. Everything! If the nurse doesn't document everything he or she does she could end up in a court of law or get fired or get a talking to from the higher ups. Back to documentation... Everything has to be in a nice neat order. Starting with Neurological, Respiratory, Gastrointestinal, Genitourinary, and finally Musculoskeletal. Now if everything is not charted correctly in scenario you get dinged!

Part 3: Nursing diagnosis and Care Plan
First, who knew that a nurse had to figure out a diagnosis for a patient. I always thought the nurse just took care of the patient. WRONG! Nurses figure out another diagnosis that realtes to the medical diagnosis.

My patient had pneumonia. With in typical pneumonia patients crackles can be heard in the lower lobes of their lungs. Som my nursing diagnosis was Impaired Gas Exchange r/t imparied alveoli gas exchange secondary to pneumonia AMB: crackles in lower lobes of lungs, dyspnea, and increased respiration rate of 24 (normal is 12-20).

Then the care plan consists of: first, a short term goal and a long term goal the patient will accomplish. Second, Assess, Do, Teach (three things to asses with this patient, three things to do to the patient, and three things to teach the patient). Third, Rationale for doing everything, however we haven't learned that part yet. And fourth, evaluation of the goals that were set. Met or not met.

Whew! that was a lot to accomplish.

You may wonder how long did I have for all of this?

Well you are just going to have to suffer because I am not going to tell you! Ha!