Senario 3 Waist belt restraint PRN; family sitter at bedside, assist with bath. Safety Disoriented to time and place, speech slurred. -Reinforce to the patient to not get out of bed Offer nutrition/toilet Verify call light/bed safety precautions Blood Glucose 185, 4 units of insulin sliding scale for coverage. Validate NPO Status Scenario 2 Skin warm dry, bruises on forehead with small laceration. Talk with her stating surgery is over and she did great. Tom Richardson Administer antipyretic medication -Reinforce the risk if patient has not been NPO and ask the patient when the last time they ate. -Provide the patient with the time when HCP will come discuss options with him Ineffective Self-Health Management False Educate patient/family Scenario 3 Ms. Gestalt is second day post-op and has requested to get out of bed and to ambulate to bathroom. 45 terms. Scenario 3 They were also concerned about the next patient going into that room and the use of the lavatory. Robert Strurgess ADA diet, intake, 25%. Assessment of bowel movement Scenario 3 Senario 4 Observe closely first hour Deficient knowledge: False The patient asks the nurse to explain about these medications and why they are in such a hurry. Amount:________ He is restless with slight confusion but is easily orientated with attempts from nurse. His partner is not with him at this time but will arrive soon to facilitate his discharge home. Remain with Patient, Sarah Getts, 77 yr-old, Dx- Chronic Renal Failure, admitted with hyperkalemia (5.9, Eq/L)/hyponatremia (128mEq/L). Scenario 5 Regular diet. You arrive in room to find Ms. Monson talking to herself. Decreased Cardiac/perfusion False He requests no visitors at this time, but later asks for his family to be called to discuss a plan of care. The charge nurse tells the nurse to take Mr. Burgundy to the floor, because his room is now ready. Determine clinical decisions based on listening to an audible client report. Widespread Color Change: N/A pallor cyanosis jaundice erythema 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". Regardez le Salaire Mensuel de Ticketmaster Beyonce Koln en temps rel. Scenario 1 Following isolation precautions, you notice several family members are by his bedside and none of them are wearing face masks as requested by sign on door. Educate patient Skin moist, respiratory bilateral wheezes and rhonchi. Obtain translator -Ensure bed is in lowest position, and rails are in place Ms. Rails was medicated with hydrocodone 5 mg PO two hours ago and is now complaining of pain (8/10 pain scale). Safety- He is experiencing new onset of shortness of breath and has a nasal cannula with 2L of Oxygen in place. How was this Students will assign correct nursing diagnosis for patients in a medical surgical virtual clinical environment. Mr. Richardson is now pain free and questioning why he is plagued with recurring urinary stones. Self-Care Deficit True Skin warm and, dry, all vital signs in WNL except 115 pulse, which is normal for him. Grieving: True When the nurse enters the room later that day to inform him that the procedure is scheduled for 1430, they see Mr. Gonzalez is sitting in front of a lunch tray. Assess for bowel sounds Chronic pain: True -Take initial vital signs (room air Pulse Ox) Constipation, risk for: True Acute Pain False Scenario 3 He is emotionally distraught, and is insisting that he be allowed to report what is going on from the ED. Acute Pain True **New Patients from 2020, Post- Covid-19 Update:** **Charlie Raymond , John Duncan, Carlos Mancia, kenny barrett, Tim Jones, Julia Monroe, Donald Lyles, John Wiggins, Richard Dominec, Preston Wright, Tom Richardson, Joyce Workman, Karen Cole, Jose Martinez, Mary Barkley Charlie Raymond (for older swift river patients see other pdf files loaded at the bottom of this file) Preston Wright Room . Scenario 5 is a 57 y/o who has been admitted for a radical prostatectomy. Sensorium Normal acuity, Physiological The provider explains that it is a pre-cancerous stage in where the cell develops abnormal features. Employ therapeutic communication: present reality Scenario 4 Visual assess It is determined that Mr. Sturgess could achieve better pain control with a PCA pump. Scenario 4 She has arrived in pre-op and about to have surgery this morning. Use therapeutic communication/Active Listening Dr. Rondeau, Educational Needs Increased acuity Check PRN pain order Senario 4 Scenario 5 Sleep Deprivation False Verbal response Oriented converses = 5 Dr. Levine, Marcella Como, 38 yr-old, Sexual Trauma Victim (Rape), unknown assailant. Strict I&O and strain all urine, filters in bathroom. Scenario 3 Do not disturb -Complete incident report. -Complete neuro checks as ordered Obtain translator Anxiety False Full assessment except 115 pulse, which is normal for him. Imbalanced Nutrition False river part Answers to the questions; Fillable SOC 1 DLA 1; Fillable SOC 1 DLA 2 - Notes on Environmental effects through sociology . Psychological Needs Increased acuity Activity as tolerated with assistance. Document and provide copy for Mr. Dominec to share with his follow up appointment tomorrow. Cough: Don Personal Protective Equipment Chronic Confusion False Swift River Clinical Practice Chamberlain University Expert James Moore Category: Nursing Description Full Document Jose Martinez Room 301 Jose Martinez, Jose Martinez, 43- year old male experiencing chest pain while watching a state rival football game earlier in the evening. No response = 1, Muscle Strength: WNL, Flaccid, Contracted Sensorium Increased acuity, Physiological Tibial: _____ + Bilateral Other: ______________ Generalized: Pedal: ______ + Bilateral Other: ____________ Sacrum: Non-pitting Pitting ___ +. Check input/output for possible dehydration Administer pain medications Document results and findings 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. Insertion site: Dry/Intact Redness Tenderness/Pain Warmth Coolness Swelling Drainage Provide information for MD to call family at home and explain what has just happened Urostomy: N/A Urostomy/Ileal conduit Scenario 1 Scenario 5 Obtain and provide the infectious disease doctor's contact information for him. Radiofrequency ablation may be recommended after endoscopic resection. Anxiety True 50% intake. Robert Sturgess Scenario 1 Mr. Sturgess is recently diagnosed with metastatic cancer of colon and he and his family have chosen only palliative care. Construct dietary consult (plan) Knowledge Deficit True Vital sign Temp 98.4, BP 136/78, P 72, RR 20, SaO2 97%. Therapeutic communication -If cardiac is suspected call the provider and the rapid response team. Document results You notice she is crying and is expressing fear that she "will always have this pain and numbness" and she doesn't think she can cope. Neuro WNL, except leg pain upon movement. Educate patient Evaluate understanding. -Inform patient to not get out of bed without assistance and place call light in reach Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. Last Bowel Movement: Date: _____________________ Constipation Diarrhea/Loose Other: You now arrive in the recovery unit one hour post-surgery and you are told that the surgery went well. Skin warm and pale. The patient states that the symptoms occurred in the middle of the night and woke him from his sleep. -Restart the IV and draw CBC -Have patient remain in bed, head elevated 30 degrees Notify family When the HCP realizes who he is, he tells the nurse to move the patient in the treatment room down the hall and put Mr. Burgundy in there. Allow for non-compliance of request Safety- Family in room with patient very concerned. -Verify that discharge orders have been written, provide discharge instructions, and in inform provider about the chest pain. Genitalia: WNL (skin intact, no lesions) Abnormalities Describe: __________________________ -Reorient Patient to person, place, & time Wash and glove hands In reassessing Ms. Monson, her vital signs are: BP -106/82, Temp-98.2, P-106, RR-18, SaO2-88. Intermittent/Continuous Other: Document results Vital assessment No Known allergies (NKA). Remind physician to wash his hands before examining the patient Scenario 1 -Tell the patient that they are being admitted to r/o any cardiac issues Blood Pressure, 7a-7p Total: 7p-7a Total: Course Hero is not sponsored or endorsed by any college or university. BP 154/89, P 94 F, R 22, T 98.3F, SaO2 95% on room air. Notify doctor SANE nurse to make second visit today. She has IV access and has received a small dose of Valium to reduce apprehension. Vital signs -Temp 98.2, BP 94/60, P72, RR 22, SaO2 99%. Background Robert Sturgess the client was admitted with Metastatic cancer of Colon, with history of diabetes. Scenario 2 Physiological- He also has a history of hypertension and takes Tenormin (Atenolol) and Atorvastatin (Lipitor). High fall risk. While assessing the patient, Mr. Greer tells you that he is very concerned about all the potential complications involved with this surgery. Full assessment including both lying/standing Breath Sounds: Clear bilaterally. Suprapubic Insertion site: WNL S/S Infection : ____________________ Nausea False Patient, and family upset regarding dx. Sexuality: True. Blood, Glucose 185, 4 units of insulin sliding scale for coverage. 97.4, Resp 16 and Pulse Ox 94%. He is excited and tells the nurse he is starving and glad that he finally gets to eat. Discharge instructions Scenario 3, Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Civilization and its Discontents (Sigmund Freud), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Psychology (David G. Myers; C. Nathan DeWall), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), The Methodology of the Social Sciences (Max Weber), Give Me Liberty! : beach pearl), in walking distance of the velgnne ferry stop, is considered the mother of all urban beach clubs. Report this activity immediately to the hospital privacy officer Scenario 3 Inappropriate words = 3 Obtain vital signs machine Full head to toe neuro assessment. Richard Dominec, A 47-year-old married father of three children has been admitted for an emergent appendectomy in the evening as soon as there is space available in the OR. Ambulates with minimal assistance. Renal diet. Educate about recovery from appendectomy and care to wound. -Remove the lunch tray and ensure pre-operative consent has been signed. No Known allergies (NKA). Self-Care Deficit False Check PRN pain order -Complete secondary assessment once the patient is in bed focusing on complaint of pain resulting from the fall -Administer the medication with a small sip of water and place an NPO sign at the entrance of the patient's room. Document results and findings Scenario 3 He also states he is feeling weak. Educational Needs Increased acuity Date of insertion: _________________________ Date of dressing: _________________________________ In the interim, start an IV and start infusing Ringers Lactate. When you enter the room, the patient is having chest pain again, and they are pale and diaphoretic. -Use therapeutic communication/active listening No known allergies (NKA). Clinical 2. Recently he manifested an unusual black lesion on his thigh and developed an opportunistic fungal mouth infection which was treated successfully. When completing the shift change neuro check, you notice the patient's left pupil is sluggish. Nutrition True But that's changing. Odor: __________, No Mr. Richardson is requesting assistance to ambulate to bathroom. Administer antiemetic medication The bed arrives tomorrow. Senario 2 Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Scenario 3 -Assess the patient's anxiety level while using therapeutic communication to decrease patients' stress. Provide a few chairs if possible for her family to also be comfortable You are now preparing for discharge, place steps in order: Senario 1 -Using therapeutic communication inform Mr. Greer that there are many treatment options, and not to leave until the HCP can come and speak with him Scenario 1 You discuss this cough with Mr. Dominec to determine how long he has had it. Arthur Thomason, 56-year-old MVA victim, fourth day post op with a splenectomy and femur repair. 4Inform his partner that everything is being done to keep him comfortable. Mr. Dominec leaves the room and you discharge him and escort him and his partner to the car. Evaluate patient understanding Wash and glove hands Gait: ______________________________, Skin Integrity Assessment Last pain medicine 2hrs ago at 1300(Demerol 50mg/ Zofran 4mg IV). Dr. Starks, Physiological Encourage fluids Wash and glove hands Inform patient about the progression and risk a PCP infection has for a patient with AIDS. Auscultate peripheral pulses and ROM. Ronald Burgundy Blood-tinged mucous, productive cough. Impaired Skin Integrity, False Tap patient and ask, "Are you okay?" Ms. Rails shares with you her fear of being discharged home to an abusive husband. Monitor and evaluate fluid intake Yes Productive Non-productive Describe Sputum: _______________________ Mrs. Smith shares with you that even though she signed the operative consent she was not sure if this was the right surgical procedure for her. Hopelessness: True -Explain to the patient that he is now considered stable, you are taking him to the hallway, and he will be admitted to an impatient room within a few hours Educate caller regarding HIPAA Evaluate understanding -Contact HCP to determine when they are available to speak with the patient RLQ: RUQ: LUQ: LLQ: Verify call light/bed safety precautions Scenario 5 Pain, Acute True Anxiety True Decreased cardio tissue perfusion: False Explain to Mr. Dominec your concern for this opportunistic infection and usual treatment. Sensorium: Normal acuity, Bleeding, risk for: False Skin Color: Consistent with ethnicity pinkish-tan light-tan dark-tan light-brown dark-brown Senario 5 The patient has been scheduled for an EGD today and has an order for Omeprazole (Prilosec) and Carafate (sucralfate). Neuro WNL, alert, and cooperative but worried about scarring and is reluctance regarding walking on leg. Scenario 3 Scenario 2 Reapply restraints Tube Feeding: Type:_________________________ Amount/Rate: ________________________ Bolus/Infusion She has just been transported from recovery. -Discuss and determine sitter availability Include patient condition change in shift report Scenario 5 LUE: Non-pitting Pitting ___+ Senario 5 Safety Increased acuity, Physiological At Risk, Impaired Comfort False -Draw a repeat CBC per HCP order to determine current Hemoglobin status Abnormal left leg weakness, gait unsteady, 5/10 on numeric pain scale. Cardiovascular has pacer with rate of 82bpm on demand. Mr. Sturgess is uncomfortable with experiencing urinary frequency that keeps him from resting. The patient got dizzy when he stood up from the commode. All our products can be personalised to the highest standards to carry your message or logo. Mr. Greer is on the floor still but is awake and oriented and is complaining of back pain below his right scapula. Vital sign assessments Assume that the oxidation state of sulfur is 2-22 and that iron atoms exist in both +2+2+2 and +3+3+3 oxidation states. Sarah Getts Mr. Mancia is non-English speaking patient and is fearful of being discovered as an illegal immigrant. Scenario 5 Ms. Rails states that she has not had a bowel movement (BM) in the past two days. 3. Impaired Mobility True Neuro WNL alert and cooperative. Chronic Sorrow False Multiple abrasions, bruising Head, chest, and inner thigh. Peripheral Neurovascular Dysfunction: False Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. He tells the nurse he has called his wife and wants to be discharged now. Mr. Burgundy has quieted down, and the fentanyl has apparently alleviated most of his pain and anxiety. Document results Lithia Monson Deficient Knowledge False Emergency intubation and assisted breathing is provided for Mr. Thomason Discuss his understanding about the plan of care. Compromised Family Coping: False Full assessment of patient. IV NS is started, and lab work is sent. Mrs. Smith's surgery has now ended. Regular diet. Scenario 2 Mrs. Stukes is feeling nauseated. Impaired Mobility, Risk for True Scenario 2 His difficulty voiding finally motivated him to seek care. Patient demonstrates urine strain procedure. You enter room and find Ms. Gestalt crying because she has just learned her medical insurance has lapsed and she is already two months behind on her car payments. Place patient on PCA pump Scenario 2 Palliative care. Scenario 4 She has received a dose of Hydrocodone for PRN pain 20 minutes ago. Wash and glove hands ASA is held but morphine 4 mg was given after his GI cocktail. Evaluate understanding Explain to physician what interventions you have recently initiated Communication/Speech: Clear Non-verbal Slurred Aphasia Other -Elevate head of bed and place the patient on Pulse oximetry. The heartburn has become worse since he started treatment for his URI. Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. Heterotrophs include (1) autotrophs, saprophytes, and herbivores (2) omnivores, carnivores, and autotrophs (3) saprophytes, herbivores, and carnivores (4) herbivores, autotrophs, and omnivores. Scenario 2 Chronic Pain False Respiratory Effort: Relaxed, Regular, Non-labored Pursed lip breathing Labored Vital signs -Temp 98.6, BP 114/62, P 100, RR 20, SaO2 94%. Scenario 3 Safety Increased acuity, Physiological Ineffective Peripheral Tissue Perfusion False Psychological Needs Normal acuity Notify lead nurse Imbalanced Nutrition: True Impaired Gas Exchange False Notify doctor if condition is abnormal You, his prior nurse, notice the family and respond to them. Educate patient Sitting, BP 109/60, P 114, Standing the patient becomes very lightheaded and the nurse has them lay back down. Encourage fluids/fiber/ambulation Begin post op education for day one Temp 98, BP 114/67, P 115, RR 20, SaO2 98%. Dr. Donofrio, Chronic Pain, Risk for constipation, impaired nutrition, anxiety, fear, grieving, hopelessness, powerlessness, Daily Flowsheet & Physical Assessment, Vital Signs Intake & Output Scenario 2 Scenario 2 Contact Social Services LOC Increased acuity Contact dietary consult He does not have an IV nor is he on oxygen. Dr. Donofrio. Educate patient Assist patient Anterior: ___________________________________ Posterior: ____________________________________ Health Change Increased acuity The client is onDemerol 25mgSlow Intravenous Push (SIVP) for pain. 20ga. Vital signs -BP 124/82, Temp 98.2, P 84, RR 22, SaO2 96%. -Notify charge nurse of patient's deteriorating condition IV D5 1/2 NS with 20 KCL @ 125 ml/hr in left forearm. Two hours later, Mr. Duncan is asked how frequent his stools have been today. Acquire daily weight and food intake Increased fall risk. Assess for fall risk Educational Needs Increased acuity Mr. Duncan's wife meets you in hall asking what she could bring her husband to eat from home. 2. Nausea: False Health Change: Increased acuity Scenario 4 Noncompliance True Vital signs -Temp 98.4, BP 116/76, P 96, RR 20, SaO2 99%. Deficient knowledge: True Scenario 1 Normal Sinus Rhythm on telemetry. Deficient Knowledge True Notify doctor When a physician makes an incision into a body cavity just superior to the diaphragm and inferior to the neck, what body cavity will be exposed?
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