Now, meeting the CDC definition, he has full blown AIDS but is asymptomatic at this time. Flexes & withdraws = 4 IV D5 1/2 NS with 20 KCL @ 125 ml/hr in left forearm. Wash and glove hands Robert Sturgess - Swift River Swift River University Nightingale College Course Concepts of Nursing I (BSN 246) Academic year2022/2023 Helpful? Mr. Gonzalez has been admitted to the floor to determine that his chest pain is not related to a cardiac event. Scenario 3 He also has metal fragments on his left side on his leg arm and torso. Educational Needs Increased acuity Disturbed Body Image True Report to charge nurse/ head nurse the need for staff education. Vital signs -Temp 98.4, BP 116/76, P 96, RR 20, SaO2 99%. Self-Care Deficit True Gait: ______________________________, Skin Integrity Assessment Non-significant past medical Hx. Impaired Comfort True Constipation False -Elevate head of bed and place the patient on Pulse oximetry. Two housekeepers, who were refusing to clean the room, are in the break room. Imbalanced Nutrition: True Pain re-assessment Mr. Duncan's wife meets you in hall asking what she could bring her husband to eat from home. Primary: Check LOC, Orientation, Breathing, Circulation, Brief Neuro assessment to include spinal pain or deformities, Obvious injuries. Evaluate patient understanding While assessing the patient, Mr. Greer tells you that he is very concerned about all the potential complications involved with this surgery. Dr. Starks, Physiological Hx of dementia, from nursing home, fall one day ago. Notify doctor Sa fortune s lve 2 000,00 euros mensuels Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. Decreased Cardiac/perfusion: False Prior to changing shift, you enter the patient's room to complete a full assessment, and Ms. Monson is now crying asking to for someone to take her home! Compromised Family Coping False -Continue to observe urine for hematuria and document findings Senario 4 All opinions are mine alone. Ms. Rails shares with you her fear of being discharged home to an abusive husband. Identify patient If patient statement differs from the surgical consent she has signed, notify surgeon immediately Vital assessment Some hair on the left side of his head has been burned off, as well. Patient and family upset regarding dx. Obtain urinary screen Validate NPO Status Obtain translatorT The patient has a Foley catheter in place and is reporting 8/10 incisional pain and he is asking why his throat is sore. Incomprehensible Cardiovascular has pacer with rate of 82bpm on demand. Abdominal Pain: Non-tender Tender/Pain Describe: Scenario 5 Fear: True Physiological- He has a 20-year one pack history of smoking. Notify doctor for Foley catheter He has a history of well controlled GERD with over-the-counter Tagamet (Cimetidine), and Tums. 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. Vital assessment Call Rapid Response protocol initiated Impaired Gas Exchange True Combien gagne t il d argent ? Students will prioritize medical surgical . Scenario 3 He is questioning the nurse as to why he has been admitted for heartburn. -Advise sitter to notify nurse when leaving the room Apical/Radial Pulse Deficit: No Yes Murmur Valve Click -Ensure there is a full O2 tank on the gurney, place patient on Nasal Cannula Educate pt regarding changes to POC Encourage fluids/fiber/ambulation Acute Pain False -Start an IV Regardez le Salaire Mensuel de Ubah Kalimat Efektif Online en temps rel. Scenario 5 Use therapeutic communication/active listening Scenario 5 He is pale, weak, diaphoretic, and appears anxious. -Document and contact nursing supervisor/Charge nurse Capillary Refill: _________ seconds Scenario 2 Radiofrequency ablation, which uses heat to remove abnormal esophagus tissue. -Transport Mr. Burgundy to his room Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. This will treat any cancer that may have metastasized to the bone. -Notify HCP of neuro findings Full assessment Ask patient to explain to you what procedure she was expecting to have this morning. No Known allergies (NKA). Read PT report Bleeding Risk for: False IV maintenance fluids with D5 1/2 NS with 20 KCL @ 125ml/hr in left forearm. Mr. Greer is on the floor still but is awake and oriented and is complaining of back pain below his right scapula. Course Hero is not sponsored or endorsed by any college or university. Psychological Needs Increased acuity 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. Verbal response Oriented converses = 5 Safety Disturbed body False Notify doctor if condition is abnormal Scenario 2 Mrs. Stukes is feeling nauseated. The patient is being prepared for discharge and his IV has been removed. Obtain and provide the infectious disease doctor's contact information for him. Request sitter/family member to bedside -Begin q15 minute neuro checks Diet as tolerated. Use therapeutic communication/Active Listening Suprapubic Insertion site: WNL S/S Infection : ____________________ Educational Needs Increased acuity Assist patient out of bed Fall Risk Increased acuity Vital signs -Temp 99.1, BP 124/62, P 77, RR 20, SaO2 91%. -Reapply the NC that he was admitted with at 2L Scenario 4 : an American History, EMT Basic Final Exam Study Guide - Google Docs, Philippine Politics and Governance W1 _ Grade 11/12 Modules SY. -Draw a repeat CBC per HCP order to determine current Hemoglobin status Scenario 3 Impaired comfort: True The patient states that the symptoms occurred in the middle of the night and woke him from his sleep. Vital signs -Temp 98.2, BP 94/60, P72, RR 22, SaO2 99%. Purposive Communication Module 2, Chapter 1 - Summary Give Me Liberty! Urostomy: N/A Urostomy/Ileal conduit Senario 1 Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. Infection, Risk for False Noncompliance False Scenario 3 Hep-Lock in place left AC. Neck: ______________ -Assess if the contents of lunch tray are intact. Nursing questions and answers. Dysfunctional Gastrointestinal Motility False Students also viewed Culture Concept notebook Development concept notebook Elimination concept notebook Gas Exchange concept notebook -Reassess patient's physical status prior to leaving him in the hallway Fear True Tom Richardson, 46yr-old. Acute Pain True Paul Greer Decreased cardio tissue perfusion: False The cancer was more advanced than they previously had thought so inguinal lymph nodes were removed. He has not had his BP medication today. She is with her physician. Therapeutic communicationT Social worker with patient this morning. Assess food consumption and intake and output -Set-up for stat portable chest x-ray Put the patient on O2 NC and Fentanyl 25mcg IVP for pain. Senario 2 Adjust crutches Mr. Mancia's vital signs upon assessment are Temp 101.2, P 94, RR 20, BP 122/82, SaO2-91%. Mrs. Pittmon states she has had numbness for years but "now I can't . Obtain Spanish signs & brochure Communication/Speech: Clear Non-verbal Slurred Aphasia Other Esteem Notify doctor Seznam uivatel, kte vlastn, prodvaj nebo shnj film. Blood-tinged mucous, productive cough. You return to the break room on your floor. Inspect cast site Allergic to sulfa drugs. Employ therapeutic communication: present reality Fall, Risk for False Love and belonging- Lithia Monson Scenario 1 Senario 5 Mr. Wright is pleasant and cooperative, but needs to be reminded to avoid pressure on his heel and sacrum. Palliative care. PT to educate patient Remind physician to wash his hands before examining the patient Non-significant past medical history. Deficient knowledge: True Mrs. Smith's surgery has now ended. 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 patient's ABC (airway, breathing, circulation) 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 -Reassess patient q 5 minutes until awake, then 15 minutes until they are fully awake (not Drowsy). Observe closely first hour Deficient knowledge: False Infection, Risk for True 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. Patient, and family upset regarding dx. Expresses fatigue, fear, concern, and desire for recovery. -Assess patient LOC, by walking patient and asking them to take deep breaths. Scenario 3 Skin Color: Consistent with ethnicity pinkish-tan light-tan dark-tan light-brown dark-brown Senario 2 Assess vital results Peripheral Neurovascular Dysfunction False Water/Flush: Vital signs taken by automatic B/P Cuff q 15 minutes Urine Color: Clarity: Odor: Type of Line: Peripheral, location ______________ CVL, location _____________ PICC, location _______________ Tubes: None Salem Sump Nasoduodenal PEG J-Tube pH: ______ Vital Signs: B: 160/92, P: 96, R: 22, SpO2: 98, T: 98.9F, 37.1C. No known allergies (NKA). Esteem He chooses to go home and see the doctor tomorrow in his office. Ineffective Airway Clearance True Scenario 5 Infection, risk for: False. Yes Productive Non-productive Describe Sputum: _______________________ Palliative care. Scenario 5 Therapeutic communication. References; Access My Virtual Clinicals; Medical-Surgical. Evaluate/Modify Mobility Plan, Carlos Mancia, 48yr-old, Spanish speaking migrant worker with no known past medical Hx. You enter his room and recognize that Mr. Thomason appears to be talking to himself and appears confused. Bowel sounds: Active, Hyperactive, Hypoactive, Absent (listen for full 5 minutes) : 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. Scenario 4 He is complaining of pain in his left arm, and pain in his left chest when he tries to take a deep breath. Bleeding False The charge nurse tells you not to move the patient, because there is no special treatment according to social status. Your response to all of them would be: Scenario 1 Oral Care -Give NS liter bolus He is experiencing new onset of shortness of breath and has a nasal cannula with 2L of Oxygen in place. -Remind patient to call for help is he need to get up and provide patient with a urinal. Assume role in response team of documenter Wife at bedside. Notify doctor Knowledge Deficit True -Assess the patient's anxiety level while using therapeutic communication to decrease patients' stress. Date of insertion: _________________________ Date of dressing: _________________________________ Other: _______________________________ Sleep deprivation: False Kathy Gestalt Cryotherapy, which uses an endoscope to apply a cold liquid or gas to abnormal cells in the esophagus. -Administer the medication with a small sip of water and place an NPO sign at the entrance of the patient's room. -If cardiac is suspected call the provider and the rapid response team. Impaired Gas Exchange False Scenario 5 Scenario 2 It is determined that Mr. Sturgess could achieve better pain control w/ a PCA pump His overall health is good, and he has known he has been HIV positive for the past five years. Educate patient regarding condition Escort patient to vehicle Scenario 5 Respiratory Rate: WNL Tachypnea Bradypnea Full head to toe neuro assessment. The patient asks the nurse to explain about these medications and why they are in such a hurry. You determine to apply the restraint now. Vital signs -BP 124/82, Temp 98.2, P 84, RR 22, SaO2 96%. She shares concern about patient's wife who is now coughing and having night sweats. -Discuss with sitter that patient needs continual observation Skin warm and dry, all vital signs in WNL 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". Several hours later, Mr. Duncan is now complaining of nausea. -Assess for fall risk -Tell the patient that they are being admitted to r/o any cardiac issues -Medicate for pain 20ga. Intermittent/Continuous Other: Respirations If family/visitors come, will need education to airborne precautions. 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. You correctly diagnosed 11 out of 16 options. Nausea False Constipation, Risk for True Health Change Increased acuity Include patient condition change in shift report Scenario 1 Scenario 4 LUE: Non-pitting Pitting ___+ Safety Impaired Skin Integrity, False Deficient Fluid Volume False When you arrive to room 4, you are told to assume the care for the patient and get ready to transport them to the floor ASAP. Upon entering room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." Then the bus splashed into the river for a cruise. Robert Domenic Spanish interpreter available at extension 61178. Pain Level Increased acuity Awaiting diagnostic labs. Senario 5 Raspberry and Cream Cheese Stuffed Blueberry French Toast with Ozery. Scenario 1 Viola Cumble Contact charge nurse. -Determine when a hospital provided sitter will be necessary Offer masks to visitors Scenario 2 No known allergies. IV maintenance fluids with D5 1/2 NS at 125ml per hour in left forearm. Assign nursing diagnosis and plan the appropriate intervention and evaluate outcomes while working through time pressure and distractions, including random call light requests. Auscultate peripheral pulses and ROM. -Reassess patient Start secondary large bore IV line Educate patient 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. Nausea False Mr. Duncan is now complaining of feeling "dizzy" when he stands. Anterior: ___________________________________ Posterior: ____________________________________ Scenario 1 Self-Actualization Check PRN pain order Scenario 4 Scenario 2 Full assessment of patient. Outline an experimental approach to demonstrate the average RNA chain growth rate during transcription of a cloned gene in vitro. -Recheck Tilts after the NS bolus is complete.T BP 154/89, P 94 F, R 22, T 98.3F, SaO2 95% on room air. Senario 4 Continue.Robert Sturgess Room 305 Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. Allow family to remain The charge nurse tells the nurse to take Mr. Burgundy to the floor, because his room is now ready. -Explain that Radium-223 mimics calcium and is absorbed during new bone growth. Flexes abnormally = 3 Document results/findings -Discuss and determine sitter availability Perform neuro assess Combien gagne t il d argent ? Mr. Dominec has a male partner and has been married for the past ten years and share their three children to the marriage. Therapeutic communication Educate patient Fall Risk: Increased acuity The surgeon has suggested Androgen-deprivation therapy (ADT) with surgical castration (orchiectomy). Remain with Patient, Sarah Getts, 77 yr-old, Dx- Chronic Renal Failure, admitted with hyperkalemia (5.9, Eq/L)/hyponatremia (128mEq/L). She has IV access and has received a small dose of Valium to reduce apprehension. Check physician orders Bleeding: True He is having some difficulty hearing and complains of ringing in his ears. John Duncan, 56yr-old male, Dx- Gastroenteritis, returned yesterday from Cancun, c/o intractable diarrhea, weak, pale, and refusing to eat. Scenario 5 Also worth mentioning is the 'Alter Schwede' - a 217t . Notify family Palliative care. Safety Color:__________ 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. 2Provide comfort in pre-surgical room Mr. Dominec. Scenario 4 Acute pain: False He states, "This is not serious." Assess Love and Belonging Apply oxygen Nausea: False Vital signs are to be taken BID, and it is now time. Notify housekeeping. Pulses: Strength & Symmetry Edema: Ineffective Renal Perfusion, Risk for True Health Change Increased acuity Pain Level Normal acuity No known allergies (NKA). Educate about recovery from appendectomy and care to wound. Urinary Catheter: N/A Indwelling Short-term Indwelling Long-term Date of Insertion:________ Size: _____F You escort them with you to the ICU. Apical pulse rhythm: Regular Irregular Location: Ineffective airway clearance True Vital signs -Temp 98.6, BP 114/62, P 100, RR 20, SaO2 94%. palliative care. Wash and glove hands Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. Sensorium Normal acuity, Physiological They wanted to know and pressure you for the information. Acute Confusion False NPO with small amount of ice chips only. Impaired home maintenance mgmg r/t client or family: False He requests no visitors at this time, but later asks for his family to be called to discuss a plan of care. His CP is 7/10 and his BP is 165/96, P 92, R 18, SaO2 98 on 2L NC. Scenario 3 Palliative care. Call rapid response He told the nurse that he has had some changes in his bowel habits and his stools have been very dark. Discuss follow up with his doctor. -Check on patient/sitter hourly 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. 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. Scenario 2 Fall, risk for: False Mr. Gonzalez has returned from his EGD and is still sleeping from the sedation. He insists that he is not hungry and refuses assistance with his meal. Verify Call Light/Bed Safety precautions You are now preparing for discharge, place steps in order: Senario 1 Electrolyte Imbalance False The patient has a pneumothorax that requires a chest tube placement. Perineal Care What is the ratio of Fe\mathrm{Fe}Fe (II) atoms to Fe(III) atoms in this compound? -Reinforce to the patient to not get out of bed Assess intake and output and possible reasoning Impaired mobility: False IV fluids of D5 1/2 NS are infusing at 100 mL/hour to his right forearm. No known allergies (NKA). Dr. Anderson, Educational Needs Increased acuity Family in room with patient very concerned. 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. Provide for physical and thermal comfort. Scenario 3 Notify lead nurse/doctor Anxiety True The patient is awake, alert, and oriented. DSD (dry sterile dressing), forehead laceration clean and dry intact. Regular diet. Disoriented to time and place, speech slurred. Deficient knowledge: True Robert Sturgess Scenario 1 Mr. Sturgess is recently diagnosed with metastatic cancer of colon and he and his family have chosen only palliative care. His orthostasis is normalized after a second liter of NS was administered. Connect telemetry You are about to call the Surgical ICU and give report. Scenario 4 Senario 3 -Notify charge nurse Hx of dementia, from nursing home, fall one day ago. Deficient Fluid Volume True Assess After washing and gloving hands, you then identify yourself and the patient, Ann Rails. Sarah Getts Neuro WNL alert and cooperative. Fall Risk Increased acuity Respiratory Rhythm: Regular Rhythmic Irregular Periods of Apnea Cheyne-Stokes Peripheral Neurovascular Dysfunction False You have them remain with you, seated in comfortable place, while you call ICU and attempt to locate physician for them. Color:__________ Ramona Stukes, 69 yr-old, third day post-op cholecystectomy. To access your Swift River Virtual Clinicals login to ATI's Student Portal and access the Virtual Clinical card in My ATI. Now, third day post-op, Mrs. Stukes appears sad and depressed upon entering the room. Scenario 3 Scenario 1 How was this 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. Stay with patient for surgeon's arrival to explain intended surgical procedure Scenario 4 Senario 1 There is an order to apply a waist belt restraint if needed. Scenario 2 Ronald Burgundy Ms. Getts is now complaining of sudden sharp, substernal chest pain, very short of breath and is profusely diaphoretic. The patient tells the nurse that yesterday he was, "concerned about having an erection, and now they want to cut off my testicels". Carlos Mancia 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 Grieving: False Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. Powerlessness True. -Inform patient to not get out of bed without assistance and place call light in reach Shock False Needs frequent reminding due to determination to do things herself without assistance. Impaired Home Maintenance Management r/t Client or Family False Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Psychological Needs Normal acuity Vital sign Temp 98.4, BP 136/78, P 72, RR 20, SaO2 97%. Secondary: Assess vital signs, auscultate heart, lungs, and bowl sounds. 97.4, Resp 16 and Pulse Ox 94%. Crutches at bedside adjusted for height. Imbalanced Nutrition False Spiritual Distress False. Fall, Risk for True Swift River Medical-Surgical. 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.

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