Remain with patient She has just been transported from recovery. Fall, Risk for True Decreased Cardiac/perfusion False Therapeutic communicationT -Advise sitter to notify nurse when leaving the room Some hair on the left side of his head has been burned off, as well. Impaired Skin Integrity False Senario 5 Scenario 5 Scenario 4 Ask patient to explain to you what procedure she was expecting to have this morning. -Call security for assistance and compliance officer Encourage Mr. Dominec to discuss with his partner his best treatment options. Observe closely first hour Students will form a preliminary assessment based on reported assessment data for medical surgical patients in a virtual clinical environment. 1. 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! Her husband who is present states, "I thought it was just a lumpectomy she was having this morning." Acute Pain True Stoma status: Pink-Red/Moist Dusky Retracted Excessive bulging Skin moist, respiratory bilateral wheezes and rhonchi. Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. When you enter the room, the patient is having chest pain again, and they are pale and diaphoretic. Filmotka filmu Najvyia ponuka (2013). -Medicate for pain The bed arrives tomorrow. Chronic Sorrow False You enter patient's room. He has a history of well controlled GERD with over-the-counter Tagamet (Cimetidine), and Tums. Normal Sinus Rhythm on telemetry. Skin Integrity: Intact No, describe below, Location Type Size Wound bed Drainage Visual assess -Notify HCP of neuro findings -Perform admission assessment Mr. Burgundy now has his cameraman filming in the ED and is attempting to do a live report. Senario 2 Assess vital results The patient will be discharged today, and he will be ordering new prescriptions. Fall, risk for: True Reapply restraints Scenario 3 Recently he manifested an unusual black lesion on his thigh and developed an opportunistic fungal mouth infection which was treated successfully. Neuro WNL, alert, and cooperative but worried about scarring and is reluctance regarding walking on leg. Mrs. Pittmon states she has had numbness for years but "now I can't . John Duncan NPO with small amount of ice chips only. Scenario 5 -Ensure there is suction in the room, and check Ronald Burgundy Stoma Status: Pink-Red/Moist Dusky Retracted Excessive bulging Include patient condition change in shift report Document Procedure -Reinforce to the patient to not get out of bed She is also to receive radiation, chemotherapy, and hormone therapy post operatively. -Discuss effectiveness of sitter You enter room one hour after the physician has left the patient. Sexuality: True. View Swift River Reflection Questions (1).docx from NRSG 4412 at South College. Opening Title Production company Cast and crew Genre J A N U A R Y 2: The Killing of John Lennon: IFC First Take: Andrew Piddington (director/screenplay); Jonas Ball, Krisha Fairchild, Gunter Stern, Gail Kay Bell, Mie Omori, Robert C. Kirk: Crime, Drama: 4: One Missed Call: Warner Bros. Pictures / Alcon Entertainment / Kadokawa Pictures: Eric Valette (director); Andrew Klavan (screenplay . Students will prioritize medical surgical . Decreased Cardiac/perfusion: False No known allergies (NKA). -Remove the dinner tray and make sure the diet is soft food. Scenario 5 Obtain Clinical Hours 24/7/365 In-Class and Lab Learning Resource Improve Clinical Practice Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. -Explain to the patient that because of his weakness and unknown cardiac status as well as the IV, he is a fall risk and should not get out of bed without assistance. Fall Risk Increased acuity Scenario 2 You arrive in room to check on her, after washing hands. Obtain patient record and follow patient as he is transferred to ICU Health Change Increased acuity Generalized weakness, blood tinged urine and severe pain upon urination, GI- n/v. Document results and findings The sister of Mr. Mancia calls from home to speak with you. Retrieve cast removal tool Obtain Spanish signs & brochure -Place patient on 100% O2 Nathaniel Gonzalez Knowledge Deficit True -Medicate for pain She shares concern about patient's wife who is now coughing and having night sweats. -Explain that Radium-223 mimics calcium and is absorbed during new bone growth. You are concerned about preventing the patient from falling. I need to be reporting!" Observe closely first hour Mr. Mancia is holding Catholic Rosary in hand and is crying as you enter the room. Scenario 2 Read PT report Acute Confusion True Notify charge nurse that discharge will probably not occur today. Senario 3 Fall Risk Increased acuity Scenario 1 Report this activity immediately to the hospital privacy officer Bleeding, Risk for False Re-assess patient Psychological Needs Normal acuity -Reassess patient's physical status prior to leaving him in the hallway Present health assessment including B/P and LOC and dressing. Provide emotional support. Noncompliance True. Procedure is canceled for the day and rescheduled later allowing for new consent. Imbalance nutrition: True Scenario 4 Lithia Monson They feel that you should share with them if he was a "real AIDS" patient or not. You also notice the patient is more difficult to orient. Fall Risk Increased acuity -Assess if the contents of lunch tray are intact. Respiratory Rhythm: Regular Rhythmic Irregular Periods of Apnea Cheyne-Stokes Therapeutic communication Iron forms a sulfide with the approximate formula Fe7S8\mathrm{Fe}_7 \mathrm{~S}_8Fe7S8. Regardez le Salaire Mensuel de Tthuchicago Org en temps rel. Obtain translatorT Provide a few chairs if possible for her family to also be comfortable 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. He also complains that his throat is still very sore. Scenario 1 Tunneled, site _______________ Implanted port, accessed _____________________ Health Change: Increased acuity Gastrointestinal Assessment Shock, Risk for False Check PRN pain order Evaluate understanding Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions StuDocu University Keiser University Western Governors University -Obtain chest tube tray and set-up pleurovac Oral Care Pain affecting: N/A Sleep Activity Exercise Relationships Appetite Concentration Talk with her stating surgery is over and she did great. Apply fall risk bracelet Hopelessness False. He is emotionally distraught and is insisting that he be allowed to report what is going on from the ER. She has received a dose of Hydrocodone for PRN pain 20 minutes ago. Peripheral Neurovascular Dysfunction: False Impaired home maintenance mgmg r/t client or family: False Upon assessment, you determined that she is confused to person, time, and place but is easily directable. Safety Sleep deprivation: False Senario 4 00 Comments Please sign inor registerto post comments. Kathy Gestalt, 33yr-old, Dx- second day post-op open right Tibia/Fibula fracture, plaster cast in place on right lower leg. , a 58-year-old male patient presents to the ER CO CP 10/10. Robert Sturgess Scenario 1 Mr. Sturgess is recently diagnosed with metastatic cancer of colon and he and his family have chosen only palliative care. Acute Pain: True Reassure patient and help explain any new orders from physician to patient Sa fortune s lve 1 900,00 euros mensuels Carlos Mancia Color:__________ Explain that he will probably not be going home at least until his doctor sees him. He is pale, weak, diaphoretic, and appears anxious. He has been taking his HIV medication daily. -Offer nutrition/toilet Regardez le Salaire Mensuel de New King James Bible Download For Windows 7 en temps rel. Radiofrequency ablation may be recommended after endoscopic resection. Isolative, appears fearful, crying, and refusing to see her husband. Vital assessment 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. Vital signs -Temp 98.2, BP 94/60, P72, RR 22, SaO2 99%. Mr. Sturgess does not have a living will or durable power of care completed. Purposive Communication Module 2, Chapter 1 - Summary Give Me Liberty! In the interim, start an IV and start infusing Ringers Lactate. Document teaching moment. Seznam uivatel, kte vlastn, prodvaj nebo shnj film. Inspect cast site Scenario 4 Construct dietary consult (plan) Allow family to remain Neuro WNL's, alert and cooperative. Scenario 3 Educate caller regarding HIPAA Scenario 4 Scenario 4 Vital assessment Nursing questions and answers. Scenario 2 Mrs. Stukes is feeling nauseated. Refer call to contact health department Adjust crutches Impaired comfort: True Educate patient Safety Imbalanced Nutrition False Full head to toe neuro assessment. Sa fortune s lve 2 000,00 euros mensuels Two housekeepers, who were refusing to clean the room, are in the break room. She has been admitted to the floor with complaints of numbness in her right foot and ankle. Acute Confusion False Hopelessness True 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. Powerlessness True. Mr. Greer has just been visited by his wife. When she moves him to the hallway, Mr. Burgundy begins yelling at you "Do you know who I am, I demand a room! Disturbed body False Perform pain re-assessment If the source voltage for the a phase is Van=12080V\mathbf{V}_{a n}=120 \angle{ 80^{\circ}} \mathrm{V}Van=12080V, and the line impedance is zero, find the phase currents in the wye-connected source. Dr. Donofrio, Physiological Encourage fluids/fiber/ambulation The charge nurse tells you she will send someone to assist you, and to get out 2mg of Versed to have ready to sedate the patient at time of procedure. Because of the fall the provider has recommended that he stay in the hospital another night. Scenario 2: 1Educate about recovery from appendectomy and care to wound. Scenario 5 ADA diet, intake 25%. Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma. Wash and glove hands Scenario 2 You take his vital signs which are: Temp 101.3, Pulse 88, Resp 24, B/P 116/84. Electrolyte Imbalance False -Complete initial post-op assessment Strict I&O and strain all urine, filters in bathroom. Sensorium Normal acuity, Physiological Impaired Gas Exchange True Begin post op education for day one Yes Productive Non-productive Describe Sputum: _______________________ Assume role in response team of documenter Document results -Start IV Respiratory Effort: Relaxed, Regular, Non-labored Pursed lip breathing Labored The nurse arrives and sees a tent is being erected as a triage area, and ambulances are lined up delivering trauma patients. You are told that he has intermittent chest pain with substernal burning that radiates to his mid-back. Fall, Risk for True Strict I&O, regular diet, intake 50%. The nurse was told by the gastroenterology nurse that they really struggled before they called anesthesia and they may have caused an esophageal abrasion. Peripheral Neurovascular Dysfunction False. IV maintenance fluids with D5 1/2 NS at 125ml per hour in left forearm. Non-significant past medical history. Incomprehensible -Inform Mr. Burgundy that he cannot report from the ED, as patient privacy is strictly protected by HIPPA The heartburn has become worse since he started treatment for his URI. Odor: __________, No Recent blood gases demonstrate falling PaO2 (hypoxemia) and increasing CO2 (Hypercapnia). Secondary: Assess vital signs, auscultate heart, lungs, and bowl sounds. and the GI cocktail given in the ER did relieve his CP but not completely. Evaluate caller understanding Scenario 3 IV maintenance fluids with D5 1/4 NS @ 150 ml/hr X 3 then reduce rate to 75 ml/hr. No Known allergies (NKA). Scenario 4 Ms. Gestalt capillary refilling is now 6 secs below cast site, extremity is swollen and cold to the touch. Acute Pain True The patient has a Foley catheter in place and is reporting 8/10 incisional pain and he is asking why his throat is sore. -Discuss with family sitter if there are any other family members who can help with monitoring Lithia Educate patient Teach Cameron. Neuro WNL alert and cooperative. ExplanationAnxiety/ fear True Pain Level: Increased acuity No Known allergies (NKA). Breath Sounds: Clear bilaterally. Evaluation patient after consult Administer antipyretic meds Scenario 3 Skin integrity at risk True Fall, risk for: True Bleeding False Scenario 2 Scenario 2 Scenario 2 To access your Swift River Virtual Clinicals login to ATI's Student Portal and access the Virtual Clinical card in My ATI. -Reapply the NC that he was admitted with at 2L Skin integrity, impaired True Allow for non-compliance of request Vital signs -Temp 98.4,BP 178/105, P 112, RR 28, SaO2 94%; Neuro- WNL's. Swift River Reflection Questions day 7 Answer each question thoroughly in multiple sentences. Scenario 2 Wash and glove hands His original lymph node biopsy was negative. Ms. Rails states that she has not had a bowel movement (BM) in the past two days. Infection, Risk for False You determine to apply the restraint now. Impaired mobility: False Assess Mr. Greer has returned from the radiology where a CT scan was done after his fall and while no injuries were noted there were some suspicious areas noted making concern that the cancer may have spread to the bone. swift river assignment: day swift river assignments dosage minimum score 90 med minimum score 80 minimum score 90 robert sturgess linda yu linda pittmon carlos Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions Keiser University Silver Creek High School (Colorado) -Offer nutrition and/ or toileting Chronic pain: True -Ensure patients is positioned in bed properly Scenario 4 He is questioning the nurse as to why he has been admitted for heartburn. Head/Face: Symmetric Asymmetric Drooping Since the finding was low-grade dysplasia and is considered the early stage of precancerous changes, the gastroenterologist recommends another endoscopy in six months, with additional follow-up every six to 12 months. Scenario 1 Escort patient Upon entering the room, the patient appears to be trying to get out of bed Three hours later, Ms. Getts is unsteady when standing by her bedside. Health Change Increased acuity Scenario 1 Color:__________ Roger Clinton, 57-year-old male construction worker arrives at 0600 to be prepared for a partial thyroidectomy to determine if he has cancer. Scenario 4 No Known allergies (NKA). -Tell the wife that you will speak to the husband, and this is apprehension is expected with this surgery/diagnosis. 20 ga. Hep-Lock in right forearm, skin warm and dry, generalized weakness with recent weight loss. The nurse performs tilt test, Patient vital signs lying flat, BP 118/62, P 92, R 20, T 98.5, SpO2 97. Risk for Infection True No response = 1, Range of Motion: Full, Limited Consult Social Service Health Change Increased acuity Comfort/Pain Assessment Wash and glove hands Fall, risk for: False Ms. Getts is being transferred as an emergency to Critical Care. Swift River Medical-Surgical. Document results You now arrive in the recovery unit one hour post-surgery and you are told that the surgery went well. Educational needs: Increased acuity Impaired Skin Integrity, False Anxiety True He is aware that he may not have an erection and may need depends for bladder incontinence. -Reassess patients' vital signs, and place on q5 minutes continuous monitoring Review pain medication order Linen Change Combien gagne t il d argent ? Love and belonging Cross), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Week #7 Assignment - Incentive Spriometer . Chronic Pain False Notify doctor if condition is abnormal Imbalanced Fluid Volume, Risk for True Impaired skin integrity: False, Anxiety: True -Start an IV D/C plan- decrease pain and restore normal gait. Describe the physical changes from aging and the care required. Sleep Deprivation False -If gastric reflux is suspected administer PRN antacids (GI cocktail) Upon entering room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." Full assessment Mr. Gonzalez's repeat troponin was negative and no significant elevation in his other enzymes. Notify doctor of change in condition in particular: unproductive cough and low-grade fever. Renal diet. Scenario 5 Vital signs -Temp 99.1, BP 124/62, P 77, RR 20, SaO2 91%. Scenario 4 : beach pearl), in walking distance of the velgnne ferry stop, is considered the mother of all urban beach clubs. NKDA Assessment The client vital signs are: Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%, Neuro WNL alert and cooperative. Provide comfort measures Skin warm and dry, all vital signs in WNL -Explain that Docetaxel is a hormone therapy that suppresses the testosterone that your testicles produce producing similar results as surgical intervention. He has a history of hypertension and is not compliant with medication. : an American History, EMT Basic Final Exam Study Guide - Google Docs, Philippine Politics and Governance W1 _ Grade 11/12 Modules SY. He has a 20-year one pack history of smoking. Patient demonstrates urine strain procedure. Aggravating Factors: Document results. NG tube to low suction possibly D/C'd today after Dr. Levine rounds. Needs frequent reminding due to determination to do things herself without assistance. Request time she can arrive and staff to help with transfer His partner is not with him at this time but will arrive soon to facilitate his discharge home. Palliative care. DSD (dry sterile dressing), forehead laceration clean and dry intact. Document results Senario 4 0800 1200 Apply restraint Mr. Dominec decides he does not want to see Infectious Disease doctor about his new cough. Safety- Noncompliance False Sa fortune s lve 2 216,00 euros mensuels -Place patient on O2 Nasal Canula -Restart the IV and draw CBC -Instruct Mr. Burgundy and his cameraman to stop immediately Abnormal left leg weakness, gait unsteady, 5/10 on numeric pain scale. Educational Needs Increased acuity Her husband and children remain with her in the surgical holding area awaiting transport to the OR. It is determined that Mr. Sturgess could achieve better pain control with a PCA pump. Tom Richardson Self-Care Deficit: True Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. Imbalanced Nutrition: True Oral Mucosa: Tongue: Teeth: Notify family Continent: Yes No Brief/Diaper 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. Therapeutic Communication Use therapeutic communication/Active Listening Virginia Smith Impaired Home Maintenance management r/t client or family False -Set-up for stat portable chest x-ray Glasgow Coma Scale 0-15 Musculoskeletal Document pt's statements. Document results Mr. Mancia's vital signs upon assessment are Temp 101.2, P 94, RR 20, BP 122/82, SaO2-91%. Abdominal Pain: Non-tender Tender/Pain Describe: Obtain urinary screen Monitor and evaluate fluid intake -Discuss with sitter that patient needs continual observation They would also like to start Radium-223. Constipation, risk for: True Grieving False Perform pain reassessment -Document and contact nursing supervisor/Charge nurse Scenario 3 -Reorient Patient to person, place, & time Scenario 2 Leave to break room and not continue in conversation. Notify lead nurse/doctor Pain, Acute True Neuro WNL alert and cooperative. The provider advises the Nurse to draw a stat CBC, give a liter bolus of NS, and repeat CBC.