Fundamentals Take Home Exam

Ms. S is a 58-year-old African American woman who is directly admitted to your unit with complaints of chest pressure and indigestion associated with nausea and vomiting. She started feeling ill about 3 hours before admission. She told the nurse she tried drinking water and took some bismuth subsalicylate (Pepto-Bismol) that she had in her bathroom medicine cabinet. She also tried lying down to rest, but none of these actions helped. She says, “It just gets worse and worse.”  She rates the pain 5/10 and says that it is a dull, achy pain that stays in the middle of her chest.  Ms. S has been under a physician’s care for the past 12 years for management of hypertension and swelling in her ankles. She takes a “pink pill and a water pill.” She was a smoker but quit 1 year ago.
Admission laboratory tests, including levels of cardiac markers, were performed and a 12-lead electrocardiogram (ECG) was taken.   The ECG shows sinus tachycardia with frequent premature ventricular contractions (PVCS…).
Ms. S’s vital sign values on admission are as follows:
Blood Pressure: 174/92 mm Hg
Heart Rate: 120 to 130 beats/min, irregular
Oxygen saturation: 94% on room air
Respiratory rate: 30-34 breaths/min
Temperature: 99.8 Degrees F (oral)

1. Write an SBAR note that would be used to discuss the case with the physician.

2. Explain and give rationale for your recommendations (the “R” of the SBAR)

3. Of the recommendations that you suggest to the physician, which do you implement first?  Support your answer with rationale.  Be sure to support why the other orders/medications would not be given first.

4.  You assign the nursing assistant the task of taking the patient’s vital signs every 15 minutes and recording the vital sign values in the electronic chart.  Later you check the chart and discover that the vital sign measurements have not been recorded.   What is your best response to the nursing assistant?

5.  Once Ms. S has stabilized she says to you “I suppose I have to change my diet.  What am I supposed to eat now?”  What type of a diet would you suggest for Mrs. S?  Support your answer with rationale.

6.  Write a nursing care plan to include subjective and objective data, 1 nursing diagnosis, NOC, and NIC.  Be sure to include rationale for the NIC. The nursing diagnosis maybe of your choosing but should be related to the scenario above.

7.  Write 1-2 paragraphs reflecting on what you learned through this project.

Fundamentals Take Home Exam
Rubric

1.  Write an SBAR note – 5 points
5 – The SBAR is written in correct format.  The information is in the correct component of the SBAR.  The note is thorough, complete, and concise.  It is apparent that there is an excellent understanding of the SBAR and what an effective SBAR looks like.
4 – The SBAR is written in correct format.  The information is in the correct component of the SBAR.  The note is complete and concise.  It is apparent that there is a very good understanding of the SBAR and what an effective SBAR looks like.
3 – An attempt is made at creating an SBAR but the note is not complete and concise or logical or is not in correct format.
2 – The information is incomplete, confusing, and does not reflect a usable SBAR.
1 – Information does not relate to the SBAR.
0 – Information is absent.

2. Recommendations (the “R” of the SBAR) – 5 points
5 – The question is answered thoroughly and is supported with rationale from a variety of professional or peer-reviewed sources.  The recommendations are appropriate and show a strong knowledge of the interventions (recommendations).  Rationales are present and come from a variety of professional and peer reviewed sources.
4 – The question is answered and is supported with rationales from limited sources.  The recommendations show knowledge of the disease and problem. Rationales are present and come from a limited number of professional and peer reviewed sources.
3 – An attempt is made to answer the question/s but the recommendations are not accurate for the disease or problem and/or not supported with rationale from professional or peer reviewed sources.
2 – The information is incomplete, confusing, and does not show understanding of the disease or problem.  Rationales are not provided.
1 – Information does not relate to effective recommendations.
0 – Information is absent

3. Priority Implementation – 5 points
5 – The question is answered thoroughly and is supported with rationale from a variety of professional or peer-reviewed sources.  The recommendations are appropriately prioritized and show a strong knowledge of the interventions (recommendations).  Rationales are present and come from a variety of professional and peer reviewed sources.
4 – The question is answered and is supported with rationales from limited sources.  The recommendations are prioritized and show knowledge of the purpose of the interventions (recommendations). Rationales are present and come from a limited number of professional and peer reviewed sources.
3 – An attempt is made to answer the question/s but the recommendations are not accurately prioritized or supported with rationale from professional or peer-reviewed sources.
2 – The information is incomplete, confusing, and/or is not prioritized to provide positive patient outcomes.  Rationales are not provided.
1 – Information does not relate to effective prioritization.
0 – Information is absent.

4.  Communication – 5 points
5 – The question is answered thoroughly and is supported with rationale from a variety of professional or peer-reviewed sources.  The communication response is appropriate for the scenario and shows a strong knowledge of effective communication techniques.
4 – The question is answered and is supported with rationales from limited sources.  The communication response is appropriate for the scenario and shows knowledge of effective communication techniques
3 – An attempt is made to answer the question/s but is not thoroughly answered or supported with rationale from professional or peer-reviewed sources.  The communication response has limited positive effect and shows a limited knowledge of effective communication techniques.
2 – The information is incomplete, confusing, and/or arranged in such a way that it is difficult to judge how it relates to the scenario.
1 – Information does not relate to the scenario.
0 – Information is absent

5.  Diet – 5 points
5 – The question is answered thoroughly and is supported with rationale from a variety of professional or peer-reviewed sources.  The diet and/or patient teaching is appropriate for the disease in the scenario and shows research on the topic.
4 – The question is answered and is supported with rationales from limited sources.  The diet and/or patient teaching is appropriate for the disease in the scenario.
3 – An attempt is made to answer the question/s but is not thoroughly answered or supported with rationale from professional or peer-reviewed sources.  The diet and/or patient teaching is not appropriate for the disease in the scenario.
2 – The information is incomplete, confusing, and/or arranged in such a way that it is difficult to judge how it relates to the scenario.
1 – Information does not relate to the scenario.
0 – Information is absent.

6.  Write a nursing care plan (using the 6 column template found in LP5) to include subjective and objective data, 1 nursing diagnosis, NOC, and NIC.  Be sure to include rationale for the NIC. 5 points
5 – The nursing care plan is complete and includes the data, nursing diagnosis (NANDA-approved), NOC, NIC and rationales for interventions.  The outcomes are measurable and include time frames.  The interventions are realistic and include a variety of resources that show thorough research.
1 point will be deducted for missing or incomplete data, nursing diagnosis, NOC, NIC (including failure to use a variety of sources) or rationales.

7.  Write 1-2 paragraphs reflecting on what you learned through this project. 2 points
2 – The reflection is thoughtful and insightful, and includes positive experiences as well as areas of new knowledge or growth
1 – The reflection is somewhat thoughtful and/or insightful and an attempt is made to evaluate the experience
0 – The reflection is missing

8.  References are in APA format. Correct spelling. 3 points
3 – Student appropriately cites sources.  The paper is typed, with correct spelling, grammar and is neat, and easy to read.
2 – The paper is legible and includes some citations.  There are some spelling and grammar issues, or is difficult to read.
1 – No use of APA or citations.  The paper is sloppy (may include spelling and grammar issues)
0 – The work is not professionally presented.