Nursing faculty teaching resource
Observer reference
Facts for the observer
Keep this page beside the observer worksheet. Check the words heard against these facts without giving the outgoing learner the model answer.
- Patient
- Diane Foster, 68 years; fictional MRN 730516
- Location
- 5 West, room 521
- Admission
- Postoperative day 1 after laparoscopic cholecystectomy for acute cholecystitis. Observation continues after nausea and limited oral intake; discharge awaits intake and mobility review.
- History / status
- Hypertension; no known medication allergies; full code
- Latest assessment
- At 6:15 p.m.: alert, oriented, no nausea or dizziness; incisions clean and dry. Pre-dose pain 4/10 at the incision with movement; patient goal 3/10 or less.
- Recent medication
- Acetaminophen 650 mg orally at 6:15 p.m., administered under the existing order.
- Mobility / intake
- Tolerating oral fluids. Fall precautions and one-person assistance for walking under the current care plan.
- Vitals at 6:15 p.m.
- Blood pressure: 128/76 mmHg; Heart rate: 82/min; Respiratory rate: 16/min; Oxygen saturation: 97% on room air; Temperature: 98.6 °F (37.0 °C)
Plan and uncertainty
Reassess pain at 7:15 p.m., one hour after the oral dose. Assist with toileting when requested; check pain and dizziness before standing and provide one-person assistance. If pain remains above the goal, reassess and contact the covering surgical clinician for review of the pain plan. Promptly report new or increasing abdominal pain, fever, vomiting or changed vital signs; use the emergency pathway for deterioration.
The response to the recent acetaminophen dose is not known. The patient requests help to the bathroom; provide one-person assistance. A correct handoff identifies this uncertainty and transfers the reassessment to a named nurse at the supplied time.
Credit equivalent wording and an appropriate interpretation. Do not credit an invented improvement or a reassessment described as already completed.