Attempt to orient to person, place, and time Fall Risk Increased acuity Observe closely first hour #1: _________, No Senario 1 He is emotionally distraught, and is insisting that he be allowed to report what is going on from the ED. Allergic to sulfa drugs. Evaluate/Modify Mobility Plan, Carlos Mancia, 48yr-old, Spanish speaking migrant worker with no known past medical Hx. He is questioning the nurse as to why he has been admitted for heartburn. He was recently treated for a URI with a Z pack, prednisone, and Motrin for pain. Document Results, Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. He is currently febrile with temperature 100.8, HR 99, BP 135/96, RR 20, PaO2 96%, nauseated with no vomiting, rebound tenderness in right lower quadrant, has elevated WBC's and surgeon feels this will be uneventful even though he has just been diagnosed with AIDS this past week. NPO with small amount of ice chips only. Assess You enter room one hour after the physician has left the patient. Assess for bowel sounds Reassure patient of options Safety Acute Pain True Document results and findings Scenario 3 Do not probe further You also notice the patient is more difficult to orient. ADA diet, intake, 25%. The nurse arrives and sees a tent is being erected as a triage area, and ambulances are lined up delivering trauma patients. The patient is asking you where her son is, the last place she saw him was right before the explosion. c/o headache- medicated with Lortab 5mg PO at 0900, takes Lomotil 10ml PRN q 4 hours last dose at 0834. Grieving: True Visual assess Read PT report Scenario 4 Three hours later, Ms. Getts is unsteady when standing by her bedside. Use therapeutic communication/Active Listening 2. Provide emotional support. Safety- Genitourinary Assessment You are now preparing for discharge, place steps in order: Senario 1 Scenario 5 Gastrointestinal Assessment Scenario 2 Mrs. Stukes is feeling nauseated. Also worth mentioning is the 'Alter Schwede' - a 217t . Communication/Speech: Clear Non-verbal Slurred Aphasia Other Last Bowel Movement: Date: _____________________ Constipation Diarrhea/Loose Other: He has a history of hypertension and is not compliant with medication. Chronic Confusion False Odor: __________, No Palliative care. -Obtain chest tube tray and set-up pleurovac -Set-up for stat portable chest x-ray 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) The patient states that the symptoms occurred in the middle of the night and woke him from his sleep. Endoscopic resection, which uses an endoscope to remove damaged cells to aid in the detection of dysplasia and cancer. Scenario 5 Family Health III-Pediatrics (NSG 6435) Emergency Medical Technician (EMS 1150) Applied Research In Business (MIS 781) Anatomy & Physiology I With Lab (BIOS-251) Molecular Biology (BP 723) Newest Marketing Management (D174) Professional Application in Service Learning I (LDR-461) Professional Capstone Project (PSY-495) Theology (104) You arrive in room to find Ms. Monson talking to herself. She is also investigating bone marrow transplantation. Senario 2 Seznam uivatel, kte vlastn, prodvaj nebo shnj film. Document results Dr. Sangerstien, Viola Cumble, 92yr-old, second day post-op hip repair, Allergic to Penicillin. Deficient Knowledge True Remain with patient and reassure -Perform neuro assess Scenario 5 **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 . Electrolyte Imbalance False Fall, Risk for True Check PRN pain order Bowel sounds: Active, Hyperactive, Hypoactive, Absent (listen for full 5 minutes) Scenario 5 He has partial thickness burns to his left arm and the left side of his face. He states, "This is not serious." Crutches at bedside adjusted for height. Pulse Ox: ___________ % on ____________FiO2; Room Air; Delivery Device Deficient Knowledge False -Medicate for pain Senario 3 -Tell the patient that they are being admitted to r/o any cardiac issues Wound clean dry and intact. Scenario 2 Place pt on PCA pump Report current urinary output quantify per hour and color of urine Imbalance nutrition: True 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. -Use therapeutic communication/active listening Several hours later, Mr. Duncan is now complaining of nausea. No Known allergies (NKA). Skin cool to touch and appears pale. Scenario 4 Scenario 3 Next time we'll spend our 60 on some food and nice beers. She has just been transported from recovery. Rich Dad, Poor Dad (Robert T. Kiyosaki) The Methodology of the Social Sciences (Max Weber) Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.) . Acute pain: False Notify lead nurse Date of insertion: _________________________ Date of dressing: _________________________________ Ruth Cummings Trustee Vice Chair Audit Chair . Imbalanced Nutrition True Inappropriate words = 3 Document results Fall, risk for: True 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! Scenario 1 Skin Color: Consistent with ethnicity pinkish-tan light-tan dark-tan light-brown dark-brown Wash and glove hands Evaluate/modify plan of care Senario 4 NKDA Assessment The client vital signs are: Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%, Neuro WNL alert and cooperative. The patient describes this pain as a heavy pressure with intermittent stabbing. Ms. Getts is being transferred as an emergency to Critical Care. Retrieve cast removal tool The patient will be discharged today, and he will be ordering new prescriptions. Tom Richardson, 46yr-old. Fall, Risk for True -Discuss with family sitter if there are any other family members who can help with monitoring Lithia Robert Sturgess Robert Sturgess 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. GI WNL. Reasses temp in 1 hour. Robert Strurgess Primary: Check LOC, Orientation, Breathing, Circulation, Brief Neuro assessment to include spinal pain or deformities, Obvious injuries. -Discuss and determine sitter availability -Check patency of Foley catheter, urine color, and ensure it is secure to the patient's leg Listen to patient concerns -Notify HCP of neuro findings jasmine . Stoma Status: Pink-Red/Moist Dusky Retracted Excessive bulging His CP is 7/10 and his BP is 165/96, P 92, R 18, SaO2 98 on 2L NC. They would also like to start Radium-223. Constipation, risk for: True A special lowbed has been ordered that will lower to the ground. Document results and findings except 115 pulse, which is normal for him. ExplanationAnxiety/ fear True Cardiovascular has pacer with rate of 82bpm on demand. Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. Dysfunctional Gastrointestinal Motility False Obtain urinary screen Bleeding Risk for: False 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. Abnormal left leg weakness, gait unsteady, 5/10 on numeric pain scale. Document teaching moment. ADA diet, intake 25%. Some hair on the left side of his head has been burned off, as well. Continue.Robert Sturgess Room 305 Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. Scenario 1 Fear: True is a 57 y/o who has been admitted for a radical prostatectomy. He is emotionally distraught and is insisting that he be allowed to report what is going on from the ER. Mr. Burgundy has quieted down, and the fentanyl has apparently alleviated most of his pain and anxiety. Impaired Urinary Elimination True Wife at bedside. Place patient on PCA pump Encourage to ambulate with assistance to void if needed Document results When the nurse retunes to the room the patient tells the nurse that when he went to the bathroom he became very lightheaded. Education of Foley Cath Procedure Scenario 3 Notify doctor of change in condition in particular: unproductive cough and low-grade fever. Notify doctor The charge nurse tells you to get the Mr. Burgundy to the hallway because six more patients are inbound, and we need to clear out our trauma-bays. Verify call Light/bed safety precautions He is married, and his wife is requesting to stay at his side. Esteem Severe pain (10/10) medicated q 30 minutes x4 with IV Morphine 2mg with little relief. Mr. Sturgess is recently dx w/ metastatic cancer of colon and he and his family have chosen only Yes 3Check surgical consent for correct procedure and make sure operative site is marked. Dr. Donofrio, Chronic Pain, Risk for constipation, impaired nutrition, anxiety, fear, grieving, hopelessness, powerlessness, Daily Flowsheet & Physical Assessment, Vital Signs Intake & Output Normal Sinus Rhythm on telemetry. Vital signs -Temp 98.6, BP, Erma Willis, a 65-year-old woman with a history of adenocarcinoma and multiple past episodes of related secondary infections, was admitted to the medical-surgical unit this morning with a diagnosis, Reflective Journal VCBC Post work Cellular Regulation VCBC Post Work Start Assignment Due No Due Date Points 10 Submitting a file upload Please submit your post work to Canvas within 48 hours of, Typically the concept of cellular regulation Involves the study of cancer and related diagnoses. Call rapid response Verify call light/ bed safety precautions Notify family as to when they may come and visit. John Duncan, 56yr-old male, Dx- Gastroenteritis, returned yesterday from Cancun, c/o intractable diarrhea, weak, pale, and refusing to eat. Senario 3 Ineffective airway clearance True Mr. Mancia's vital signs upon assessment are Temp 101.2, P 94, RR 20, BP 122/82, SaO2-91%. The charge nurse tells the nurse to take Mr. Burgundy to the floor, because his room is now ready. Scenario 2 Psychological Needs Normal acuity Scenario 1 Safety- Scenario 5 Deficient Fluid Volume False Ineffective self-health mgmt: False, Disturbed body: False Pain Level Increased acuity Tunneled, site _______________ Implanted port, accessed _____________________ Scenario 3 Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him.
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