Attain fluids/fiber diet and assisted ambulation Perform pain re-assessment Fall, risk for: False Cardiovascular has pacer with rate of 82bpm on demand. Fall Risk: Increased acuity Acute Confusion True Mr. Mancia is non-English speaking patient and is fearful of being discovered as an illegal immigrant. Safety Encourage fluids Abdominal Pain: Non-tender Tender/Pain Describe: Scenario 2 Mr. Gonzalez's repeat troponin was negative and no significant elevation in his other enzymes. August 13, 2020 // by Angela McGowan. Consult Social Service Failure to Thrive False. Ineffective Self-Health Management True : an American History (Eric Foner), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Psychology (David G. Myers; C. Nathan DeWall), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Respiratory Assessment Disturbed Sensory Perception False Scenario 3 Bed Bath: Assist or Total Several hours later, Mr. Duncan is now complaining of nausea. Ms. Getts is now complaining of sudden sharp, substernal chest pain, very short of breath and is profusely diaphoretic. You correctly diagnosed 11 out of 16 options. Evaluate understanding Obtain urinary screen -Reassess patient Auscultate peripheral pulses and ROM. Document conversation Document results and findings Notify lead nurse/doctor Fear/Anxiety True. Scenario 2 -Reapply the NC that he was admitted with at 2L Report this activity immediately to the hospital privacy officer He is pale, weak, diaphoretic, and appears anxious. Scenario 2 fallout 4 save wizard quick codes death and wheel of fortune tarot combination; gambling meaning in english urdu alpine spiced apple cider gluten free; how to use v2ray samsonas sequential gearbox subaru; lg magic remote power light stays on Scenario 3 Recent blood gases demonstrate falling PaO2 (hypoxemia) and increasing CO2 (Hypercapnia). Notify doctor and charge nurse Impaired Mobility True -Draw a repeat CBC per HCP order to determine current Hemoglobin status His overall health is good, and he has known he has been HIV positive for the past five years. Provide comfort in pre-surgical room Mr. Dominec. Neuro WNL alert and cooperative. References; Access My Virtual Clinicals; Medical-Surgical. He was recently treated for a URI with a Z pack, prednisone, and Motrin for pain. He has a history of hypertension and is not compliant with medication. -Start an IV Awaiting transport. Mr. Gonzalez has returned from his EGD and is still sleeping from the sedation. Dr. Rondeau, Educational Needs Increased acuity Psychological Needs Normal acuity Offer bedpan Blood, Glucose 185, 4 units of insulin sliding scale for coverage. Assess for bowel sounds No known allergies (NKA). When she moves him to the hallway, Mr. Burgundy begins yelling at you "Do you know who I am, I demand a room! Notify charge nurse that discharge will probably not occur today. Tear, Ecchymosis, Contusions, Bruising His wife tells the nurse that he seemed very distant and did not want to talk much. Cryotherapy, which uses an endoscope to apply a cold liquid or gas to abnormal cells in the esophagus. Temperature is now 102.8. Document results Infection, Risk for True Adjust crutches Impaired comfort: True Esteem NURS 320 Med_Surg_Swift_River **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 Document results Comfort/Pain Assessment Wash and glove hands Scenario 1 Scenario 5 Noncompliance True Scenario 3 Safety Scenario 3 Scenario 3 Bleeding Risk for: False Senario 2 -Medicate for pain He states, "This is not serious." Health Change Increased acuity Ineffective Renal Perfusion, Risk for True Health Change Increased acuity Scenario 4 Senario 4 Escort patient to vehicle Document results. Severe pain (10/10) medicated q 30 minutes x4 with IV Morphine 2mg with little relief. Neuro WNL, except leg pain upon movement. Teach patient about safety when getting out of bed The pathology report shows no cancerous lesions. Pregnancy and labor and delivery are not typically associated with the concept of cellular regulation, Patient: Donald Lyles,52-year old male, was admitted yesterday evening for stabilization of his uncontrolled type II diabetes. Ms. Getts is being transferred as an emergency to Critical Care. No known allergies (NKA). Reasses temp in 1 hour. Wound site clean, dry and intact NPO, NG-tube to low continuous suction. Encourage fluids Mr. Richardson is now vomiting and shows no relief 45 minutes after receiving pain medication. Communication/Speech: Clear Non-verbal Slurred Aphasia Other Widespread Color Change: N/A pallor cyanosis jaundice erythema Scenario 5 -Inform Mr. Burgundy that he cannot report from the ED, as patient privacy is strictly protected by HIPPA Urine Color: Clarity: Odor: Educate patient Dr. Anderson, Educational Needs Increased acuity Grieving: False. Scenario 2 High fall risk. Other: _______________________________ After leaving the room the provider tells the nurse that he hopes that he scared him into compliance with the treatment options. Background Robert Sturgess the client was admitted with Metastatic cancer of Colon, with history of diabetes. Vital signs -Temp 98.2, BP 94/60, P72, RR 22, SaO2 99%. Determine from medical record if partner is aware of his recent AIDS diagnosis. Educate patient 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. 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. Scenario 4 Determine clinical decisions based on listening to an audible client report. Robert Domenic Scenario 1 Urostomy: N/A Urostomy/Ileal conduit Verify call Light/bed safety precautions Acute pain: True Construct dietary consult (plan) The patient will be discharged today, and he will be ordering new prescriptions. Acute Confusion False Biopsies were sent to determine the treatment. Document Results, Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. Family in room with patient very concerned. He warns the patient that if he does not comply with the treatment and preventive measures, he will need other treatments that may include. He does not have an IV nor is he on oxygen. Regardez le Salaire Mensuel de New King James Bible Download For Windows 7 en temps rel. Scenario 1 Perform neuro assess Notify doctor of change in condition in particular: unproductive cough and low-grade fever. Impaired Skin Integrity, Risk for True Inform patient about the progression and risk a PCP infection has for a patient with AIDS. Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. Ms. Rails was medicated with hydrocodone 5 mg PO two hours ago and is now complaining of pain (8/10 pain scale). The patient got dizzy when he stood up from the commode. Take vital signs before leaving the hospital again. Your Swift River Virtual Clinicals account has been linked to your ATI Student account. I need to be reporting!" 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! Assess vital results No known allergies (NKA). Upon entering the room with a translator to admit him to the hospital, he is asked for address and phone number but refuses to comply. Senario 4 Tunneled, site _______________ Implanted port, accessed _____________________ After 3 hours, Ms. Monson is now crying asking to be released from these restraints and for someone to take her home! student name date: nur 113 assessment swift river patient: robert sturgess handoff robert sturgess, 81 years old, metastatic ca of colon, hx of diabetes. They would also like to start Radium-223. The surgeon has just visited with Mr. Greer 2-days post op and has informed him that the lymph node biopsies have confirmed that the cancer has metastasized, and he will need further treatment. Education of Foley Cath Procedure Verify Call Light/Bed Safety precautions Document results -Notify HCP of neuro findings -Recheck Tilts after the NS bolus is complete.T Wash and glove hands Mr. Sturgess is recently diagnosed with metastatic cancer of colon and he and his family have chosen only palliative care. : beach pearl), in walking distance of the velgnne ferry stop, is considered the mother of all urban beach clubs. Skin: Warm/dry Clammy/diaphoretic Skin Turgor: Brisk Tenting Increased fall risk. -Explain to the patient that he has a procedure, and he cannot eat. The cells are allowed to warm up and then are frozen again. Neuro WNL alert and cooperative. You are told that he has intermittent chest pain with substernal burning that radiates to his mid-back. Full assessment There is an order to apply a waist belt restraint if needed. Scenario 1 Decisional Conflict False Students will form a preliminary assessment based on reported assessment data for medical surgical patients in a virtual clinical environment. Check monitor Sa fortune s lve 2 216,00 euros mensuels Physiological- Today's incentive spirometry Tidal Volume is 1250ml, improvement over yesterday's 900ml. Head/Face: Symmetric Asymmetric Drooping Decreased Cardiac/perfusion False Dr. Brown, Educational Needs Increased acuity Rapid Response team arrived including anesthesia. After two hours, Mr. Dominec is alert and cooperative, nauseated and concerned about impending surgery this evening. When completing the shift change neuro check, you notice the patient's left pupil is sluggish. -Reinforce to the patient to not get out of bed Allow husband to come into recovery for a quick one-minute visit. The patient describes this pain as a heavy pressure with intermittent stabbing. Deficient knowledge: True Safety- Excess Fluid Volume, Risk for False Neuro- confusion to time and place, but oriented to self, speech clear, poor historian, did not recognize son today which is new for her; Neuro assessment and vital signs q1 hr. The heartburn has become worse since he started treatment for his URI. -Discuss effectiveness of sitter "I am feeling fine." Knowledge Deficit True Radial: ____ + Bilateral Other: _____________ RLE: Non-pitting Pitting ___ + -Ask the patient if it is okay to discuss his care in front of his children. Her husband and two grown children are also with her as she is prepared with gown and head cap awaiting transport to the operating room. She has been documented as being obese, new onset. Ambulates with minimal assistance. Love and belonging Scenario 1 Patient and family upset regarding dx. Scenario 2 You return to the break room on your floor. Bowel sounds: Active, Hyperactive, Hypoactive, Absent (listen for full 5 minutes) Vital signs taken by automatic B/P Cuff q 15 minutes Skin moist, respiratory bilateral wheezes and rhonchi. Pain Level Increased acuity Skin Integrity: Intact No, describe below, Location Type Size Wound bed Drainage Ms. Cumble states that she has not had a BM for three days. You have them remain with you, seated in comfortable place, while you call ICU and attempt to locate physician for them. Psychological Needs Increased acuity Lithia Monson Place call light and check bed for safety Skin warm and dry, all vital signs in WNL He also has metal fragments on his left side on his leg arm and torso. Encourage to ambulate with assistance to void if needed Bleeding False Fall, risk for: True Skin warm dry, bruises on forehead with small laceration. Scenario 5 He insists that he is not hungry and refuses assistance with his meal. Present health assessment including B/P and LOC and dressing. Assess toe movement and capillary refilling Viola Cumble Scenario 4 -Offer nutrition and/ or toileting Her pitcher has already been filled three times this shift. RLE: ______________ LLE: ______________, Casts/Splits: ____________________________, Motor response Verbal command = 6 Evaluate/modify plan of care Reapply restraints Upon assessment, you determined that she is confused to person, time, and place but is easily directable. Nutrition True Capillary Refill: _________ seconds This information is HIPAA protected and you cannot share anything with them. Respiratory Effort: Relaxed, Regular, Non-labored Pursed lip breathing Labored Apply oxygen Combien gagne t il d argent ? Deficient knowledge: True Senario 3 Ann Rails Scenario 4 BP 154/89, P 94 F, R 22, T 98.3F, SaO2 95% on room air. Constipation False -When the HCP arrives, stay in the room to determine whether you can continue care with the patient Hopelessness: True Pain Scale: 0 to 10: _______________ -Teach the patient that there are several interventions for complications post-prostatectomy to include erectile dysfunction, post-op prostatectomies, and self-care involved with a foley catheter at home. Safety Pain Level Normal acuity Educational Needs Increased acuity Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. IV maintenance fluids with D5 1/4 NS @ 150 ml/hr X 3 then reduce rate to 75 ml/hr. Deficient Knowledge False Impaired Comfort True Fall, risk for: True Scenario 5 -Medicate for pain -Ensure patients is positioned in bed properly Mr. Mancia is holding Catholic Rosary in hand and is crying as you enter the room. -Call security for assistance and compliance officer Reassure patient and help explain any new orders from physician to patient Dr. Suculo, Physiological -Reassure patient that he will be moved to a private room as soon as possible Generalized weakness, blood tinged urine and severe pain upon urination, GI- n/v. Diet as tolerated. 20 ga. Hep-Lock in right forearm, skin warm and dry, generalized weakness with recent weight loss. Mr. Greer has just been visited by his wife. Impaired skin integrity: False, Anxiety: True ExplanationAnxiety/ fear True 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. Teach Cameron. Check input/output for possible dehydration ADA diet, intake, 25%. Talk with her stating surgery is over and she did great. Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. Mr. Wright is pleasant and cooperative, but needs to be reminded to avoid pressure on his heel and sacrum. Fall, Risk for True Spanish interpreter available at extension 61178. Fall, Risk for True Course Hero is not sponsored or endorsed by any college or university. He is emotionally distraught, and is insisting that he be allowed to report what is going on from the ED. Do not probe further Nathaniel Gonzalez Notify family as to when they may come and visit. Impaired Gas Exchange True IV maintenance fluids with D5 1/2 NS with 20 KCL @ 125ml/hr in left forearm. Administer antiemetic medication He also states he is feeling weak. Use therapeutic communication/Active Listening Paul Greer Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. Notify lead nurse/doctor Nursing questions and answers. Carlos Mancia Deficient Knowledge False -Explain that Radium-223 mimics calcium and is absorbed during new bone growth. -Determine when a hospital provided sitter will be necessary No 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) Fatigue True Arthur Thomason, 56-year-old MVA victim, fourth day post op with a splenectomy and femur repair. Evaluate outcome of dietary plan Imbalanced Nutrition True Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Scenario 2 Dr. Altace, Educational Needs Increased acuity Intermittent/Continuous Other: Acute Pain True Sensorium Increased acuit, Physiological Scenario 4 Fatigue True Assess intake and output and possible reasoning He has a history of well controlled GERD with over-the-counter Tagamet (Cimetidine), and Tums. He requests no visitors at this time, but later asks for his family to be called to discuss a plan of care. Oral Mucosa: Tongue: Teeth: Recent chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes. Sleep deprivation False Mr. Richardson is now pain free and questioning why he is plagued with recurring urinary stones. All opinions are mine alone. Safety Place patient on PCA pump He was initially sedated with versed 2mg, and Fentanyl 100 mg by the EGD nurse, but the patient was not tolerating the procedure, so anesthesia was called to administer propofol. palliative care. -Reorient Patient to person, place, & time Leave to break room and not continue in conversation. Family arrive one hour after event to his prior room and find Mr. Thomason's room is empty and have no idea of the events that have just occurred. Notify Doctor for pain medz Sensorium: Normal acuity, Bleeding, risk for: False Put the patient on O2 NC and Fentanyl 25mcg IVP for pain. Combien gagne t il d argent ? Read PT report Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma. -Reassess patients' vital signs, and place on q5 minutes continuous monitoring Vital signs -BP 124/82, Temp 98.2, P 84, RR 22, SaO2 96%. -Discuss with family sitter if there are any other family members who can help with monitoring Lithia -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. Shock False Chronic Pain False Scenario 2 Place pt on PCA pump Ambulates with assistance. Now, third day post-op, Mrs. Stukes appears sad and depressed upon entering the room. Robert Sturgess - Swift River Swift River University Nightingale College Course Concepts of Nursing I (BSN 246) Academic year2022/2023 Helpful? 156 terms. Document results/findings ADA diet, intake 25%. Scenario 1 Regardez le Salaire Mensuel de Ubah Kalimat Efektif Online en temps rel. Impaired Skin Integrity, Risk for False Senario 1 Safety- Ineffective self-health mgmt: False, Disturbed body: False Bleeding, Risk for False -Tell the patient that they are being admitted to r/o any cardiac issues Tube Feeding: Type:_________________________ Amount/Rate: ________________________ Bolus/Infusion jessdevan. His, Joyce Workman Room 303 Joyce Workman Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Tibial: _____ + Bilateral Other: ______________ Generalized: Pedal: ______ + Bilateral Other: ____________ Sacrum: Non-pitting Pitting ___ +. Combien gagne t il d argent ? Document teaching moment. : an American History (Eric Foner), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Safety Scenario 5 Notify housekeeping. Senario 3 The nurse identifies self to the nurse triaging patients and is directed to trauma room 4. She is also investigating bone marrow transplantation. Safety Increased acuity, Physiological Fall, risk for: True -Give NS liter bolus Dr. Jones. Hx of dementia, from nursing home, fall one day ago. The patient tells the nurse that yesterday he was, "concerned about having an erection, and now they want to cut off my testicels". It is determined that Mr. Sturgess could achieve better pain control w/ a PCA pump Scenario 1 Your response to all of them would be: Scenario 1 Verify call light/bed safety precautions While assessing the patient, Mr. Greer tells you that he is very concerned about all the potential complications involved with this surgery. Explain to Mr. Dominec your concern for this opportunistic infection and usual treatment. Virginia Smith Educate patient Vital signs -Temp 98.4, BP 116/76, P 96, RR 20, SaO2 99%. LUE: Non-pitting Pitting ___+ Scenario 4 -Provide a diversional activity to pass the time while waiting on the HCP and inform wife that the HCP will be coming soon Multiple abrasions, bruising Head, chest, and inner thigh. No weight bearing today. Now, meeting the CDC definition, he has full blown AIDS but is asymptomatic at this time. Explain reason for assessment and procedure -Perform neuro assess Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Senario 1 Powerlessness True. Respiratory Rate: WNL Tachypnea Bradypnea Give verbal report -Reassess patient q 5 minutes until awake, then 15 minutes until they are fully awake (not Drowsy). Scenario 1 Scenario 2 Administer antipyretic medication -Discuss with sitter that patient needs continual observation NKDA Assessment The client vital signs are: Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%, Neuro WNL alert and cooperative. Anxiety True A new graduate nurse receives a call from the hospital telling them to report to the ER immediately for a disaster. He is complaining of pain in his left arm, and pain in his left chest when he tries to take a deep breath. Vital sign assessments Sensorium Normal acuity, Physiological Tom Richardson, 46yr-old. Scenario 5 Impaired Skin Integrity, Risk for False Skin warm and, dry, all vital signs in WNL except 115 pulse, which is normal for him. Scenario 3 Mr. Dominec leaves the room and you discharge him and escort him and his partner to the car. The nurse was told by the gastroenterology nurse that they really struggled before they called anesthesia and they may have caused an esophageal abrasion. Scenario 4 Tom Richardson Scenario 1 Pain Level Increased acuity Water/Flush: His left humerus is fractured and splinted. Anterior: ___________________________________ Posterior: ____________________________________ Scenario 4 r/o Tuberculosis. Document findings Do not disturb Apical Pulse Rate: Heart Sounds: Normal S 1 S 2 S 3 Health Change Increased acuity Upon entering room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." Re-assess patient Scenario 5 Two housekeepers, who were refusing to clean the room, are in the break room. Dr. Roopes, Estelle Hatcher, 31yr-old, r/o appendicitis, 1st day post-op appendectomy; No known allergies (NKA); Vital signs - Temp 101.2, BP 108/74, P 92, RR 20, SaO2 99%, alert and cooperative. Hopelessness False. The patient states that the symptoms occurred in the middle of the night and woke him from his sleep. Full assessment Contact Social Services Esteem c/o headache- medicated with Lortab 5mg PO at 0900, takes Lomotil 10ml PRN q 4 hours last dose at 0834. -Ensure patient privacy and call for help and assist patient to bed once help arrives Sitting, BP 109/60, P 114, Standing the patient becomes very lightheaded and the nurse has them lay back down. You enter patient's room. Ineffective breathing pattern False Seek clarification 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. Assess Dr. Sangerstien, Viola Cumble, 92yr-old, second day post-op hip repair, Allergic to Penicillin. The dinner tray is waiting for the patient in his room, and the nurse notices it is a regular diet. ADA diet, intake 25%. Secondary: Assess vital signs, auscultate heart, lungs, and bowl sounds. Use therapeutic communication/active listening Assessment of bowel movement NG tube to low suction possibly D/C'd today after Dr. Levine rounds. Ms. Gestalt is second day post-op and has requested to get out of bed and to ambulate to bathroom.