Tap patient and ask, "Are you okay?" But that's changing. Strict I&O and strain all urine, filters in bathroom. Health Change Increased acuity Document results. Scenario 1 Hopelessness False. Grieving: False Notify lead nurse/doctor Compromised Family Coping False The nurse observes an elderly lady who is crying and has not been taken care of yet. Social worker with patient this morning. Abdomen: Flat Rounded Scaphoid Distended Palpation: Soft Taut Rigid Swallowing: Intact Dysphagia Aspiration Precautions -Document and contact nursing supervisor/Charge nurse Neck: ______________ -Begin q15 minute neuro checks He insists that he is not hungry and refuses assistance with his meal. He has been taking his HIV medication daily. Deficient Knowledge False In reassessing Ms. Monson, her vital signs are: BP -106/82, Temp-98.2, P-106, RR-18, SaO2-88. Document results Scenario 5 The Physician tells you to have everything ready including a 22 French chest tube, and he will be in shortly to position the chest tube. Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. Biopsies were sent to determine the treatment. Scenario 2 Check surgical consent for correct procedure and make sure operative site in marked. Full assessment Radiofrequency ablation may be recommended after endoscopic resection. Sarah Getts He is complaining of pain in his left arm, and pain in his left chest when he tries to take a deep breath. -Tell the wife that you will speak to the husband, and this is apprehension is expected with this surgery/diagnosis. Scenario 4 Hopelessness True BP 154/89, P 94 F, R 22, T 98.3F, SaO2 95% on room air. Provide comfort in pre-surgical room Mr. Dominec. Lithia Monson Sensorium Increased acuity, Physiological Pulses: Strength & Symmetry Edema: Safety Swift River: Sign In Psychological Needs Increased acuity Roger Clinton, 57-year-old male construction worker arrives at 0600 to be prepared for a partial thyroidectomy to determine if he has cancer. Document and prepare to transfer to Surgical ICU The patient has sustained an injury to her head, that is bandaged, and is bleeding from a wound to her right arm and chest area. Vital signs -Temp 99.1, BP 124/62, P 77, RR 20, SaO2 91%. Sleep Deprivation False Offer assistance in providing more information about treatment options for newly diagnosed AIDS patients. Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. -Inform patient to not get out of bed without assistance and place call light in reach Document results GI WNL. Encourage fluids -Check on patient/sitter hourly Impaired Gas Exchange True -Start an IV sounds= 2 Re-assess patient -Explain to Mr. Greer that it may take several days for healing, and he may have temporary incontinence, but it will resolve over time. Scenario 4 The patient asks the nurse to explain about these medications and why they are in such a hurry. He has a 20-year one pack history of smoking. Constipation False Health Change: Increased acuity Wash and glove hands Med Surg - Swift River_2020 | NURS 320 Med_Surg_Swift_River_Graded A Document results/findings Combien gagne t il d argent ? NG tube to low suction possibly D/C'd today after Dr. Levine rounds. The surgeon believes that the surgery was successful but recommends the patient have chemotherapy and radiation postoperatively. Wash and glove hands Educate patient -Tell the patient to call immediately if the chest pain gets worse or they become short of breath Document results Cardiovascular has pacer with rate of 82bpm on demand. Scenario 4 -Offer nutrition/toilet Connect telemetry Mr. Sturgess is recently dx w/ metastatic cancer of colon and he and his family have chosen only Today's incentive spirometry Tidal Volume is 1250ml, improvement over yesterday's 900ml. -Explain to patient why his throat may be sore Obtain translator Scenario 4 Leave to break room and not continue in conversation. Remind staff that Universal Precautions are practiced at this hospital for all patients regardless of known infectious diseases. Combien gagne t il d argent ? Fall Risk Increased acuity Scenario 4 Infection, Risk for False -Provide a diversional activity to pass the time while waiting on the HCP and inform wife that the HCP will be coming soon Assess for bowel sounds Chronic Pain False Senario 3 Scenario 5 -Call security for assistance and compliance officer Health Change Increased acuity Scenario 4 Scenario 1 Imbalance nutrition: True Constipation False Notify lead nurse/doctor Disturbed Body Image True Chronic Pain False Scenario 5 Verify call light/ bed safety precautions Medical Surgical Flashcards | Quizlet Apply fall risk bracelet Then the bus splashed into the river for a cruise. Scenario 2 Senario 4 Answers to the questions - 1. Linda Yu Acuities Educational - Studocu Pulse She has been documented as being obese, new onset. Scenario 5 Anxiety False Esteem Allow family to remain Obtain patient record and follow patient as he is transferred to ICU Fortune Salaire Mensuel de Nba 2k23 Pc Review Combien gagne t il d Patients vital signs are BP: 100/58, P: 106, R: 28, PaO2: 92%, T: 97.1 F, 36.2 C. Bleeding, Risk for False Seek clarification Deficient Fluid Volume True Safety- Expresses fatigue, fear, concern, and desire for recovery. He also has a history of hypertension and takes Tenormin (Atenolol) and Atorvastatin (Lipitor). Need frequent reminder to stay in room and maintain mask precautions. You also notice the patient is more difficult to orient. -Place patient on O2 Nasal Canula Explain to Mr. Dominec your concern for this opportunistic infection and usual treatment. The ER nurse reports that his cardiac enzymes were borderline, (Troponin?, CK/CKMB?) Blood, Glucose 185, 4 units of insulin sliding scale for coverage. Place pt on PCA pump Urination: WNL Burning Frequency Urgency Scenario 1 Scenario 1 He is excited and tells the nurse he is starving and glad that he finally gets to eat. Allergic to sulfa drugs. Wash and glove hands As you enter the room, Mr. Duncan is refusing to eat foods from bland diet. Alert and cooperative. Her husband and children remain with her in the surgical holding area awaiting transport to the OR. How was this Upon entering the room, you find Mr. Sturgess is quiet, appears tense and rigid but states, Scenario 3 -Transport Mr. Burgundy to his room Blood Pressure, 7a-7p Total: 7p-7a Total: -Give NS liter bolus Safety Increased acuity, Physiological Hypothermia False -Ensure IV is patent, Lithia Monson He has not had his BP medication today. Wash and glove hands Remind physician to wash his hands before examining the patient Renal diet. Educate patient regarding condition His past symptoms for three months have been that he noticed a slight hoarseness in speaking, a slight dry cough not related to a cold, and upon examination had a "pea-size lump on the center of his neck". Educate patient Impaired Urinary Elimination True Virginia Smith, 57-year-old who has elected to have a total mastectomy based on consultation with her surgeon, a total mastectomy removes all breast tissue but leaves all or most of axillary lymph nodes and chest muscles intact. What is the ratio of Fe\mathrm{Fe}Fe (II) atoms to Fe(III) atoms in this compound? Anterior: ___________________________________ Posterior: ____________________________________ Palliative care. Esteem Use therapeutic communication/Active Listening 2021-22, Historia de la literatura (linea del tiempo), Respiratory Completed Shadow Health Tina Jones, CH 02 HW - Chapter 2 physics homework for Mastering, BI THO LUN LUT LAO NG LN TH NHT 1, Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1. Self-Actualization IV Fluids: INT lock IV Fluids ______________@ _____________ mL/hr Date on tubing: Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Chronic Pain, Risk for constipation, impaired nutrition, anxie, 4 units on insulin sliding scale for coverage, Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), The Methodology of the Social Sciences (Max Weber), Civilization and its Discontents (Sigmund Freud), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Give Me Liberty! The cells are allowed to warm up and then are frozen again. Stoma Status: Pink-Red/Moist Dusky Retracted Excessive bulging His left humerus is fractured and splinted. Review pain medication order After two hours, Mr. Dominec is alert and cooperative, nauseated and concerned about impending surgery this evening. Scenario 4 -Perform admission assessment Senario 3 Oriented to: Person Place Time Ronald Burgundy ADA diet, intake 25%. You call his doctor to inform him the family has arrived. Senario 1 Inappropriate words = 3 Assist physician in physical exam of patient Mrs. Smith's surgery has now ended. LOC Normal acuity Educate patient regarding changes to POC Palliative care. Scenario 3 Ramona Stukes, 69 yr-old, third day post-op cholecystectomy. Students will assign correct nursing diagnosis for patients in a medical surgical virtual clinical environment. You enter his room and recognize that Mr. Thomason appears to be talking to himself and appears confused. Report current urinary output quantify per hour and color of urine Arthur Thomason It is now third day post-op, the order is for Ms. Cumble to stand by bedside on both legs for 5 minutes, three times a day. Scenario 1 Document results Scenario 2 -Complete head-to-toe assessment while patient is on the floor. Her chart reports she was extubated upon arrival to the recovery area, received three units (3000 mL) of fluid, receiving O2 @ 4L via nasal cannula, has Foley Catheter in place draining QS clear yellow urine, responds to verbal stimulation, chest dressing in place remains dry and intact, and has just received a small dose of IV morphine for pain. Wash and glove hands LOC Normal acuity Odor: __________, *Types: Abrasion, Burn, Laceration, Puncture, Surgical, Pressure Ulcer, Vascular Ulcer, Maceration, Excoriation, Skin Hx of dementia, from nursing home, fall one day ago. Scenario 5 Scenario 2 Today, clubs like Hamburg City Beach Club, Lago Bay, Hamburg del Mar and StrandPauli provide a relaxed summer atmosphere with a view over the Elbe. Senario 2 Psychological Needs Normal acuity Fortune Salaire Mensuel de New King James Bible Download For Windows 7 Scenario 3 Assist patient Establish second IV Scenario 4 Electrolyte Imbalance, Risk for True Full assessment Psychological Needs Increased acuity Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. Educate patient/family List of American films of 2008 - Wikipedia Vital assessment Observe closely first hour Impaired Mobility True "I am feeling fine." Make-Up Clinic Day 3 MS - Swift River Assignment: Make-up Day 3 Swift -Verify that discharge orders have been written, provide discharge instructions, and in inform provider about the chest pain. Determine from medical record if partner is aware of his recent AIDS diagnosis. Fear/Anxiety True. The 'Strandperle' (lit. Contact head nurse or supervisor in the OR to evaluate new situation Awaiting diagnostic labs. Remind the nursing staff that the patient is NPO. Due to this, the provider would like him to stay in the hospital for observation. Read PT report Decreased Cardiac/perfusion False Self-Care Deficit True Carotid:____ + Bilateral Other: _____________ RUE: Non-pitting Pitting ___+ Swift River Med-Surg Flashcards | Quizlet All our products can be personalised to the highest standards to carry your message or logo. Safety Scenario 5 Electrolyte Imbalance False Deficient knowledge: True Scenario 1 -Offer nutrition and/ or toileting RLE: ______________ LLE: ______________, Casts/Splits: ____________________________, Motor response Verbal command = 6 Skin warm and dry, all vital signs in WNL Pain Scale: 0 to 10: _______________ Remain with patient Ms. Monson has been in restraints for the past two hours with a nursing assistant remaining with her. Report this activity immediately to the hospital privacy officer Imbalanced Nutrition: True -Assess patients' pain and rule out cardiac pain. Impaired Gas Exchange True Obtain translatorT Verify call light/bed safety precautions Deficient Knowledge True Waist belt restraint PRN; family sitter at bedside, assist with bath. student name date: nur 113 assessment swift river patient: robert sturgess handoff robert sturgess, 81 years old, metastatic ca of colon, hx of diabetes. After 24 hours, Ms. Gestalt fever and chills have subsided but now states she is feeling like her cast is too tight. -Explain that Docetaxel is a hormone therapy that suppresses the testosterone that your testicles produce producing similar results as surgical intervention. Acute Pain: True