Virtual Scenario- Diane Radford (Cholecystitis)

Prep

-Adjust curtain

-Hand hygiene

-Check ID

-Raise bed

-Lower bed rails

Communication

1. General inquiry (she then says "I'm gonna throw up."

-intervention: Elevate head of bed

2. Ask about Nausea

3. Ask about Pain (she says, "5, sharp and stabbing)

-intervention: offer her pain medication

Head and neck

Inspect:

-Facial expression Unexpected

-Skin Unexpected

-Sclerae Unexpected

Anterior chest

Inspect:

-Respiratory status Expected

-Skin Unexpected

-Turgor Unexpected

Posterior chest

Inspect:

-Skin Unexpected

Abdomen

Inspect:

-Skin Unexpected

-Contour/symmetry Expected

Auscultate:

-Bowel sounds Unexpected

Palpate:

Unexpected

Upper extremities

Inspect:

-Oxygen saturation, using oximeter Expected

-Skin Unexpected

Palpate:

-Skin Temperature Unexpected

Lower extremities

Inspect:

-Skin Unexpected

Palpate:

-Skin Temperature Unexpected

Wrap-up

-Adjust side rail

-Lower bed

-Hand hygiene

-Curtains