-Wound Cultures Administer the medication Impaired comfort elisabeth_hamilton. Scenario #4 Verify Call Light/Bed Safety precautions Constipation: False Scenario #5 Complete assessment - Infection, risk for, Scenario #1 Educate pt regarding condition Stop the platelets Initiate incident report, Acute pain Have IV ABX Document What is going on? Peripheral neurovascular dysfunction: False Announce, "CLEAR Impaired Urinary Elimination: True Two housekeepers, who were refusing to clean the room, are in the break room. Asses Mr. Wright's willingness Collect supplies Hopelessness: True Reduce stimuli in the pt room Notify family Infection, risk for: False Do not disturb Scenario 5 - Fall Risk - increased -Patient Education Check the client Orient pt and husband to the unit Request the uncle come Provide morphine Document results Perform hand hygiene and don gloves Document and provide copy for Mr. Dominec to share w/ his follow up appointment tomorrow. understands Scenario 2 Document results Orient pt. Marcella is very worried about STD's and posssible pregnancy, Scenario 1 Administer rectal Infection Contact Social Services - Noncompliance Obtain Spanish Fall Risk - normal She is 2 days post-op. Scenario #3 Pain - normal Continue frequent VS, Acute pain call report to home care RN, Educational Needs: Increased acuity Serum Sodium 142 mEq/L Change to simple O2 face mask per HCP Refer caller to contact health department Administer antipyretic meds Fear Complete physical Concepts of Nursing IV 100% (2) Deanna Concept Map Assignment 1. Ask parents Retake VS Report this activity, Bleeding, risk for 5-100% O2 has not been effective in maintaining her PaO2. Impaired Tissue Integrity: True Risk for physical injury: True Remove clean gloves 1-Enter the room, perform hand hygiene, and cancel the call light -Evaluate patient understanding of plan of care Ms. Getts is now complaining of sudden sharp, substernal chest pain, very short of breath and is profusely diaphoretic. Who were you talking to? Psychological needs: Normal acuity Fear of death Linda Yu, was admitted to your unit after surgery on her left hip due to a fall. Ms. Hatcher is second day post-op and has a NG tube set to gravity drainage only. LOC - normal Evaluate/modify mobility plan, Physiological- : an American History, Physio Ex Exercise 8 Activity 3 - Assessing Pepsin Digestion of Proteins, Lesson 8 Faults, Plate Boundaries, and Earthquakes, EES 150 Lesson 2 Our Restless Planet Structure, Energy, & Change, Assignment Unit 8 - Selection of my best coursework, Logica proposicional ejercicios resueltos, Chapter 01 - Fundamentals of Nursing 9th edition - test bank, Focused Exam Alcohol Use Disorder Completed Shadow Health, Tina Jones Heent Interview Completed Shadow Health 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. He has a history of a Myocardial Infarction, MI, one year ago, and has refused all cardiac rehab, and has not had another cardiac event. Altered body image, risk for - Pain - increased Position the pt. Scenario 3 Contact charge nurse Assess for therapeutic Fall, risk for Health Change: Increased acuity Check proper Attempt deescalation Advanced Medical Surgical Nursing New Patients Teach pt. Before entering Carlos Mancia room to administer his antipyretic medication for his recent temp of 101.2 Functional ability Use therapeutic Sarah Getts Give verbal Wash hands & assess Observe closely change diet to HH 6.) Report Maintain strict I&O's Esteem- Scenario #5 Psychological Needs - normal View VCBC Glucose Regulation Swift River.docx from NURSING 246 at Colorado Christian University. Call rapid response Prepare for external pace-maker placement 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. Perform focused respiratory assessment Request the uncle participates Safety: Increased acuity Notify doctor Asses for mediastinal shift Pain - increased Establish large IV access Offer resource Full assessment of pt Scenario #4 Scenario 3 Scenario 5 lOMoARcPSD|7327774 New Patients Swift river med . D/C instruction She is super morbidly obese with a BMI of 52, Ht, 5'3", Wt, 293lbs. She has active bowel sounds Provide pt hx of event to team Assess Mr. Jones Give tylenol Post CVA, he has developed some aphasia and is having difficulty with verbal communication. - Self-care deficit, Scenario #1 2 -Reduce external stimuli Place call light w/in reach Assess pt and family readiness to learn Use therapeutic you take his vital signs which are T 101.3, P 88, R 24, BP 116/84 Attempt to orient Assess pt. Fall Risk - increased Sensorium - increased, - Electrolyte imbalance Perform pain Psychological Needs: Increased acuity Mrs. Stukes is a failed laparoscopic cholecystectomy that resulted in a bowel resection with a temporary ileostomy in place. Apply restraint Anxiety: True Mr. Mancia is holding a Catholic Rosary in his hand is crying as you enter the room, Scenario 1 Retrieve cast removal tool Explain to Mrs. Whitmore Impaired Communication: False Apply Silvadene The pain was relieved post-op. Her temp is 100.8, BP 100/62, P 92, R 21, SpaO2 91. Reinforce dressing Ms. Rails shares with you her fear of being discharged home to an abusive husband. Scenario #1 Reassure pt. Scenario 3 Scenario 2 Safety- Scenario #4 Scenario 1 Discuss support groups, Educational Needs: Increased acuity Ask pt. Disturbed body image: False Remove infiltrated IV Peripheral neurovascular dysfunction: True. Scenario #1 Obtain a sitter - Health Change - increased Scenario #5 Fall, Risk for: True Educational needs increased Fall risk increased Health change increased Neurological normal Pain level increased Psychological need normal Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Nausea, Scenario #1 Set-up Perform neuro - Grieving You are entering the room for the first time. Assist pt. Arthur Thomason 16. Instruct Lucy to assist in maintaining pt position and field sterility Attempt to orient to person, place and time - Impaired comfort Scenario 4 Ensure the pt. Ineffective health maintenance Scenario #3 Order a new clear Deficient Fluid Volume: True Administer 100% O2 Attempt to restart IV Discuss the policy She is aware of herself and the situation, but no time or day. 2-Insert the indwelling urinary catheter Alert? Deficient knowledge: False -Have TDD device on hand Disturbed body: True Fall Risk: Increased acuity Safety- You arrive in room to find Ms. Monson talking to herself. Establish when the cardiac event time began Robert Sturgess 4. Scenario #2 Scenario 4 Family dynamics Scenario #2 Educate family regarding intervention Perform full assessment Use therapeutic Impaired mobility: False Scenario #4 Bleeding: False -IV Antibiotics Assist Ms. Horton Ask nursing manager, Acute pain Scenario #3 Verify call light Order a new clear liquid diet Educate pt - Psychological Needs - increased Pt presents to the unit c/o numbness in the rt foot and ankle and toes "not looking the right color". Document and prepare to txf to surgical ICU Medicate pt. Notify PT Obtain VS Assess pain - Pain - increased Following isolation precautions, you notice several family members are by his bedside and none of them are wearing face masks as requested by the sign on the door. Remove clean gloves, wash hands, put on sterile gloves Offer masks Other Quizlet sets. 4-Stop the conversation immediately Fear: True Prepare for external Prepare Mrs. Knox's body Scenario #2 Perform hand hygiene Grieving: True Noncompliance: True Rape-trauma syndrome 3-Have UAP gather fresh linens -The patient is still anxious, continue to comfort and reassure her, -Comfort Ann Rails Upon enter the room, she asks you if she will be able to drive when she gets home tomorrow. Offer to contact Administer pain medications Verify call light She states she leads a sedentary lifestyle as a bank officer. 1-Take her BP in both her arms Follow up w/ regular HCP in 1 week 4.) Pain Level: Increased acuity Pain - normal 4-Offer patient a tissue Evaluate medication effectiveness Reassess pt's physical Linda Yu | Mary Barkley | Linda Pittmon | John Wiggins | Swift River Your coworkers are asking you questions about mr. Dominec. Scenario 5 Grieving: True Nausea: False Complete assessment Read PT report The dx tests were completed and Dr. Gray has informed the pt of the dx of HF and tx w/ digoxin. - Fall Risk - increased joyce workman swift river quizlet joyce workman swift river quizlet. Clean wound Explain to Mr. Wiggins Inform pt. Provide medical hx including medication hx and allergies Scenario 4 has a HX Reapply NC She is frustrated and overwhelmed with the new appliance not working properly. Use therapeutic communication to comfort pt. Scenario #5 Ensure pt. Self-care deficit Place pt. Joyce Workman Scenario 1 Mrs. Workman presented to the diabetes clinic and provided a 24-hour food recall. Health Change: Increased acuity Document all findings Therapeutic communication Notify HCP of findings Contact IV team -Sit at the patient's eye level and ensure they can see your lip movement and facial expression Educate Ms. Horton that paroxetine (Paxil) is to be taken as ordered Assist pt. Assess I/O and possible reasoning Call local law enforcement, Educational - increased Auscultate Schedule Cardiac rehab Scenario 2 - Ineffective health maintenance Risk for decreased cardiac output: False of protocols Estelle Hatcher 15. Explore new ways Scenario #5 Scenario 4 Safety- Swift River_2020 | NURS 320 Med_Surg_Swift_River_Graded A - Qwivy.com Scenario 5 Isolation Precaution: False Document Following pt. Grieving: False She presses the call light w/ questions about who her RN will be and her NG-tube. Update pt. Encourage fluids Scenario 5 Assess pain and rhythm Q15 minutes Put side rails up Schedule cardiac Notify HCP It is now the second day post op and his is given discharge information. Compromised family coping: False Scenario #2 Check leads Assess the injury Scenario #4 Scenario #5 Explain rationales for pressure relief to injured areas. Acute pain: True 1-Obtain a new IV site Later in morning care, Ms. Como requests o take a shower stating she feels 'dirty'. Prepare for heparin Draw a repeat CBC -Notify HCP and nursing supervisor Educate patient was admitted 1 Ask for a copy of the advance directive Educate pt. Sensorium - normal, Scenario #1 Provide supplies Rank as most concerning for labs Acute Pain: False exam 3. Scenario #2 Scenario 5 Scenario 3 Collect pre-op labs Provide information Mr. Raymond continues to deteriorate and becomes confused. Dressing change q 24 hours to RT thighs and rt shoulder. Bleeding, risk for: True She was admitted yesterday for stabilization of her glucose levels and to assist her with lifestyle modification. Sexuality, Scenario #1 Psychological Needs: Normal acuity, Physiological Explain to Mr. Dominec LOC: Normal acuity Document results Notify social services, Educational - increased Determine from medical She has just been transported from recovery. Assist & support Safety- Pre medicate Morphine Sulfate 4mg IV 15 minutes prior to dressing change 3.) You determine to apply the restraint now. Scenario #3 Health Change - increased Contact radiology -RRT has arrived, coordinate patient care for a stat VQ scan Call HCP Measure wound size at greatest length, width and depth using a disposable paper tape measure.
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