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Scenario
You finished new graduate orientation yesterday on a general medical surgical unit, and today you
will independently care for two clients. As you receive a report on the second client at 0730, your
Preceptor stops by to ask how the first day by yourself is coming along and reminds you to complete
the final items on your training list today before the end of the 12-hour shift.
• Complete the new online training model and quiz on the sliding insulin scale.
• Complete the orientation evaluation form.
• Sign up for one of the four nursing committees.
• Complete and sign the orientation reflection journal.
• Attend the new employee luncheon from 1-2 pm sponsored by the hospital physicians.
Client 1:
• 25-year-old female 24 hours post-op from a Roux-en-Y gastric bypass
• BMI of 50
• History of hypertension and sleep apnea
• No complications post-operative
• Pain at 4 am, three on a scale of 10
• Nasogastric tube to gravity
• NPO
• Mother stayed overnight but left early this morning to shower and will return later in the
afternoon
• Waiting on morning labs
Physician orders:
• Dietary Consult
• Bariatric Behavioral Therapist Consult
• 0.45% NS intravenous infusion post op
Client 2:
• 46-year-old male admitted 72 hours prior with severe GERD and difficulty swallowing
• History of alcoholism, hypertension
• Smoked two packs per day for 22 years
• Endoscopy for Barrett’s Esophagus was negative on the day of admission
• Pain at 4 am, two on a scale of 10
• Due to resume clear liquid diet this morning
• Potential discharge later today home with family
• The ex-wife has stayed in a room with a client and has been disruptive at times demanding
pain medication and food.
• Waiting on morning labs
Medications:
• Protonix 40 mg once daily, intravenous infusion
• Switch to oral Protonix 40mg day of discharge
• IV infusion 0.9% NS 50 ml/hour
• Resume 50mg Lopressor (metoprolol) PO twice daily after rule out Barrett’s Esophagus
• 1-2mg Morphine Sulfate IV PRN q 4-6 hours for pain greater than 6 out of 10
TIME: 0800
EVENT: You prioritize the need to assess the 46-year-old male first since he has 0900 medications
and the physician is rounding and should order discharge today. Assessment and vital signs reveal
no concerns, ex-wife not present. A physician writes an order to discharge this client today. The client
asks you to return in 30 minutes and go over discharge when ex-wife is present to hear instructions.
You administer Lopressor and Protonix.
TIME: 0830
EVENT: You assess the 25-year-old post bariatric surgery client. Vital signs and morning labs are
within acceptable limits, and client reports pain two on a scale of 10. While assessing for bowel
sounds, you notice the nasogastric (NG) tube not secured to the nose, and the client reports the tube
partially came out when she blew her nose but she was able to push it back in with no pain. You
document NG tube in place and assist the client to the bathroom.
TIME: 0900
EVENT: You return to 46-year-old client and review discharge instructions with the client and exwife, discontinue the IV infusion, remove the intravenous catheter, and complete discharge summary.
TIME: 0945
EVENT: Transport stops by to take 25-year-old client to meet with a support group for bariatric
surgery clients — you okay transport.
TIME: 1000
EVENT: Physician stops into see a bariatric client and is upset you let her leave for support group
before rounding. You report no concerns, physician reviews chart and writes discharge order for later
in the afternoon if no vomiting or pain. The NG tube can be removed at noon by the Nurse
Practitioner, and a diet of clear liquids resumed at 6 pm if no vomiting or gastric distention. Call
immediately if any vomiting or signs of gastric distention occur.
TIME: 1030
EVENT: You take a break to complete orientation reflection journal, orientation evaluation, and
online sliding insulin scale training module and quiz.
TIME: 1130
EVENT: The 25-year-old bariatric client returns from the support group, you see her ambulating in
the hallway, and you notice the NG tube is missing. The client states the tube fell out of her nose
when she stood up to introduce herself. She has no complaints of nausea and no evidence of gastric
distention. You document the NG tube was removed accidentally by the client.
TIME: 1200
EVENT: 46-year-old male client calls and expresses frustration at a time to discharge. He wants to be
home by 3 pm for his son’s birthday party. You call transport who assures you and the client they will
arrive before 1 pm to discharge the client.
TIME: 1215
EVENT: Morning documentation complete, all orders are in the system, and both clients are stable.
You are amazed at how smooth the first day is going. You head to the new employee luncheon with
your Preceptor.
TIME: 1330
EVENT: You return from lunch and find the 46-year-old client discharged, and you must prepare for
a new admit from the emergency room with rule out pancreatitis. You feel apprehension since this
will be your first admit, so you reach out to your Preceptor to review policy and procedure for new
admissions.
TIME: 1345
EVENT: While working with your Preceptor, the Certified Nursing Assistant stops by and reports the
25-year-old client refused an afternoon visit from a member of the bariatric support group,
complaining of fatigue. Her noon vital signs were blood pressure 90/40, heart rate 112, and
respiratory rate 28. Your Preceptor assures you these vital signs, and fatigue often occurs with this
type of client. She susgest, the client is probably depressed, ready to go home, and suggests to let
her rest for the afternoon.
TIME: 1415
EVENT: The new admit from the emergency department arrives with two pages of physician orders
and a communication challenge since he speaks and understands only Spanish. He has pain in the
abdomen and begins vomiting. Seeing you are now very busy; the Preceptor offers to “look in” on
your 25-year-old client and will take care of any concerns. Also, she will order a translator to assist
with the new admit, while you focus on taking care of the physician orders.
TIME: 1730
EVENT: Finally, all orders for the new admit are in the system; pain decreased, no further vomiting,
and he is resting comfortably. While waiting for lab results, you decide to check on the 25-year-old
client.
TIME: 1745
EVENT: On the way to the client’s room, the Nurse Manager stops and asks you to take a moment to
fill out a volunteer form for one of the four nursing committees on the Unit.
TIME: 1815
EVENT: You return to the 25-year-old client’s room and find her unresponsive, pale, with no heart
beat or respirations. The abdomen is distended and hard. Attempts are made for resuscitation but
are not successful. The client is deceased.
TIME: 1900
EVENT: You prepare to leave to go home. The Nurse Manger stops you and asks to debrief the
situation. After reviewing the chart and discussing the situation, she is concerned and sees errors in
your judgement and actions. She is sure the client’s death will be a sentinel event and warrant a
review by the Internal Review Board.
Instructions
To prepare for debriefing with the Internal Review Board, the Nurse Manager asks you to submit an
internal memo with your analysis and perceptions of the events that occurred, including:
• Description of the errors and why they occurred.
• Align to unexpected client outcomes.
• Support choices with rationales.
• Strategies for appropriate actions to avoid errors identified and reduce risk of unexpected
outcomes.
• Support strategies with rationales, nursing theory and evidence from the literature.
• Ideas stated with professional language and attribution for credible sources with correct APA
citation, spelling, and grammar
Resources
•
Memo FAQ

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