Cystic Fibrosis

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Cystic Fibrosis

Posted at 13:15h
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Christopher Parris
Age: 18 years
Diagnosis: Cystic Fibrosis
 
Feedback Log VSIM
0:00 You arrived at the patient’s side.
0:00 You reviewed the patient information.
0:00 You reviewed the patient log.
0:00 You reviewed the diagnostics.
0:00 You reviewed the clinical observations.
0:00 You reviewed the MAR.
0:00 You reviewed the orders.
0:00 You reviewed the intake and output.
0:10 Patient status – ECG: Sinus rhythm. Heart rate: 81. Pulse: Present. Blood pressure: 121/72 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 97%. Temp: 99 F (37.3 C)
0:12 You introduced yourself. This was reasonable.
0:31 You put on gloves.
1:10 Patient status – ECG: Sinus rhythm. Heart rate: 82. Pulse: Present. Blood pressure: 122/73 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 97%. Temp: 99 F (37.2 C)
1:27 You identified the patient. To maintain patient safety, it is important that you quickly identify the patient.
1:39 You washed your hands. To maintain patient safety, it is important to wash your hands as soon as you enter the room.
2:10 Patient status – ECG: Sinus rhythm. Heart rate: 82. Pulse: Present. Blood pressure: 121/72 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 97%. Temp: 99 F (37.2 C)
2:42 You asked if the patient was allergic to anything. He replied: No, I am not allergic to anything
3:07 You asked the patient if he needed anything. He replied: I guess you need to start my tube feeding.
3:09 You asked the patient how he felt. He replied: I am tired.
3:10 Patient status – ECG: Sinus rhythm. Heart rate: 82. Pulse: Present. Blood pressure: 121/72 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 97%. Temp: 99 F (37.2 C)
3:11 You asked what happened. He replied:I havent been eating much lately.
3:13 You asked: What were you doing when the symptoms started? He replied:Nothing special.
3:16 You asked the patient if he had had anything to eat or drink today. He replied: No, I havent eaten anything yet today
3:18 You asked the patient if he felt better. He replied:No, the same.
3:19 You asked the patient what the emesis looked like. He replied:What emesis?
3:20 You asked the patient: How would you describe your coughing? Is it dry, wet, or productive? He replied:I do not have any coughing.
3:22 You asked the patient if he felt nauseated. He replied: No. I don’t have any nausea.
3:24 You asked the patient: How long have you had diarrhea? He replied: I haven’t had any diarrhea.
3:26 You asked the patient: Can I get you some water? He replied: No, thank you.
3:27 You asked the patient: Have you had any signs of dehydration such as leg cramps, palpitations, weakness, fatigue, or dizziness? He replied:No, I don’t think so.
3:28 You asked the patient: Do you binge on large amounts of food in a short period? He replied: No.
3:30 You asked the patient: Do you follow a special diet prescribed by your doctor? He replied: Yes. A high-fat, high-calorie diet.
3:32 You asked the patient: Do you follow a special diet prescribed by your doctor? He replied:Yes. A high-fat, high-calorie
3:35 You asked the patient: Do you use any vitamins or food supplements? He replied: Yes, I do take special vitamins. I have to take extra vitamins because of my CF. I dont take any supplements.
3:38 You asked the patient: Do you view yourself as overweight? He replied: No.
3:39 You asked the patient: Do you weigh yourself frequently during the week? He replied:No, I usually dont weigh myself often, but I have been weighing myself every week since I noticed I was losing weight.
3:41 You asked the patient: Has there been any pain, swelling, or discoloration around the colostomy pouch? He replied: I did not have a colostomy.
3:43 You asked the patient: Has there been any leakage from or around the pouch? He replied: I do not have a pouch.
3:45 You asked the patient: Has there been any smell, secretion, or discharge from the wound? He replied: I do not have a wound.
3:47 You asked the patient: Have you had any signs of urinary tract infection like fever, urge, or pain? He replied: No, I have not felt any of that.
3:50 You asked if the patient was allergic to anything. He replied: No, I am not allergic to anything.
3:53 You asked the patient if he had taken his medication, if any. He replied: I didn’t take my meds yet.
3:53 You asked the patient if he had any medical problems. He replied: Yes, I have cystic fibrosis.
3:56 You asked the patient if he was a smoker. He replied: No
3:57 You asked if the patient was allergic to anything. He replied: No, I am not allergic to anything.
4:01 You asked the patient if he was awake. He replied: Awake
4:02 You asked the patient what year it is. He replied:2022
4:03 You asked the patient if he knew where he was. He replied: I am in the hospital
4:05 You asked the patient what date it was. He replied: 12th
4:08 You asked the patient what date it was. He replied: 12th
4:10 Patient status – ECG: Sinus rhythm. Heart rate: 82. Pulse: Present. Blood pressure: 122/73 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 97%. Temp: 99 F (37.2 C)
4:22 You educated the patient about activities, safety, and fall risk.
4:47 You wanted to educate the patient about a bladder management program, but that was not an issue.
5:09 You attached the pulse oximeter. It is a good idea to monitor the saturation and pulse here. This will allow you to reassess the patient continuously.
5:10 Patient status – ECG: Sinus rhythm. Heart rate: 83. Pulse: Present. Blood pressure: 122/73 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
5:35 You measured the blood pressure at 118/70 mm Hg. It is appropriate to monitor the patient by measuring the blood pressure.
5:47 You looked for normal breathing. He is breathing at 12 breaths per minute. The chest is moving equally.
6:10 Patient status – ECG: Sinus rhythm. Heart rate: 83. Pulse: Present. Blood pressure: 121/72 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
6:21 You checked the temperature at the ear. The temperature was 99 F (37.2 C).
6:45 You examined the patient’s skin. There is normal elasticity of the skin. His color is normal, and he is not sweating.
7:08 You checked the radial pulse. The pulse is strong, 85 per minute, and regular. It is correct to assess the patients vital signs.
7:10 Patient status – ECG: Sinus rhythm. Heart rate: 83. Pulse: Present. Blood pressure: 119/71 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
7:23 You asked the patient if he had any pain. He replied: No,I don’t have any pain.
7:27 You tried to check the emesis basin.
7:36 You looked for normal breathing. He is breathing at 12 breaths per minute. The chest is moving equally.
8:09 You checked the pedal pulse. The pulse is strong, 85 per minute, and regular.
8:10 Patient status – ECG: Sinus rhythm. Heart rate: 83. Pulse: Present. Blood pressure: 121/72 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
8:42 You checked the capillary refill time. The capillary refill time was less than 2 seconds.
9:10 Patient status – ECG: Sinus rhythm. Heart rate: 83. Pulse: Present. Blood pressure: 122/72 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
9:20 You checked the pedal pulse. The pulse is strong, 85 per minute, and regular.
9:57 You checked the eye movements. Extraocular movements within normal limits.
10:10 Patient status – ECG: Sinus rhythm. Heart rate: 83. Pulse: Present. Blood pressure: 120/71 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
10:45 You assessed the patients neurological status. This is reasonable.
11:10 Patient status – ECG: Sinus rhythm. Heart rate: 84. Pulse: Present. Blood pressure: 121/72 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
12:10 Patient status – ECG: Sinus rhythm. Heart rate: 84. Pulse: Present. Blood pressure: 122/72 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
12:17 You should have aspirated on the nasogastric tube here to assess the gastric content.
12:42 You put an emesis basin at the bedside. This is reasonable.
13:01 You assisted the patient into a sitting position.
13:10 Patient status – ECG: Sinus rhythm. Heart rate: 84. Pulse: Present. Blood pressure: 117/70 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
13:24 You flushed the nasogastric tube. This was reasonable.
13:47 You aspirated on the nasogastric tube. This was reasonable.
14:06 You educated the patient about activities, safety, and fall risk.
14:10 Patient status – ECG: Sinus rhythm. Heart rate: 84. Pulse: Present. Blood pressure: 119/71 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
14:34 You educated the patient about body mass index.
15:08 You educated the patient about coughing.
15:10 Patient status – ECG: Sinus rhythm. Heart rate: 84. Pulse: Present. Blood pressure: 117/70 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
16:10 Patient status – ECG: Sinus rhythm. Heart rate: 84. Pulse: Present. Blood pressure: 119/71 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
16:13 You educated the patient about dehydration.
16:45 You educated the patient about diagnostics.
17:10 Patient status – ECG: Sinus rhythm. Heart rate: 84. Pulse: Present. Blood pressure: 119/71 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
17:28 You educated the patient about diet. This was reasonable.
17:54 You educated the patient about intake and output.
18:10 Patient status – ECG: Sinus rhythm. Heart rate: 84. Pulse: Present. Blood pressure: 115/69 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
18:19 You educated the patient about medication.
18:39 You educated the patient about personal protective equipment.
19:04 You educated the patient about positioning.
19:10 Patient status – ECG: Sinus rhythm. Heart rate: 84. Pulse: Present. Blood pressure: 118/70 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
19:22 You educated the patient about risk of aspiration.
20:01 You educated the patient about tube feeding. This was reasonable.
20:10 Patient status – ECG: Sinus rhythm. Heart rate: 84. Pulse: Present. Blood pressure: 118/71 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
20:37 You educated the patient about use of incentive spirometer.
21:10 Patient status – ECG: Sinus rhythm. Heart rate: 84. Pulse: Present. Blood pressure: 117/70 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
22:10 Patient status – ECG: Sinus rhythm. Heart rate: 84. Pulse: Present. Blood pressure: 116/69 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
22:43 You compared the medication label with MAR. This was reasonable.
22:54 A 5-tablet dose of pancrelipase was given orally. It is important to use the basic rights of medication administration to ensure proper drug therapy. This was indicated by order.
23:10 Patient status – ECG: Sinus rhythm. Heart rate: 84. Pulse: Present. Blood pressure: 117/70 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
23:47 You compared the medication label with MAR. This was reasonable.
23:56 You started a 480 mL tube feeding of fluid nutrition 1.5 kCal/mL at 60 mL/hr. This was indicated by order.
24:10 Patient status – ECG: Sinus rhythm. Heart rate: 84. Pulse: Present. Blood pressure: 117/70 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
24:29 You educated the patient about body mass index.
25:10 Patient status – ECG: Sinus rhythm. Heart rate: 84. Pulse: Present. Blood pressure: 118/71 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
25:12 You educated the patient about diagnostics. It is important to ask patients with cystic fibrosis about their bowel movements.
26:10 Patient status – ECG: Sinus rhythm. Heart rate: 84. Pulse: Present. Blood pressure: 117/70 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
26:32 A patient handoff was performed.
This patient has been hospitalized for management of cystic fibrosis and associated weakness and weight loss. He reports fatigue, and he has had a recent 6 kg (13.2 lb) weight loss. He was diagnosed with cystic fibrosis as an infant and has had multiple hospitalizations for respiratory and nutritional support. A nasogastric (NG) tube has been placed for feedings. Students are expected to assess his nutritional status, assess vital signs, administer oral medications, begin tube feeding, and educate the patient about his nutritional needs. The steps for administering feedings are similar regardless of the tube used. Feeding can be provided on an intermittent or continuous basis. Position the patient with the head of bed elevated at least 30 to 45 degrees or as near normal position for eating as possible. This position minimizes the possibility of aspiration into the trachea. Assure correct placement of the feeding tube before administering the feedings. The nurse should ensure proper placement of the NG tube by relying on multiple methods and not on one method alone.

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