You take his vital signs which are: Temp 101.3, Pulse 88, Resp 24, B/P 116/84. Remain with patient Apical pulse rhythm: Regular Irregular Location: Scenario 2 Skin cool to touch and appears pale. Inappropriate words = 3 Mr. Dominec had his surgical procedure and is doing great. Wash and glove hands Educate patient regarding patient care Ramona Stukes, 69 yr-old, third day post-op cholecystectomy. Psychological Needs Normal acuity -Discuss with family sitter if there are any other family members who can help with monitoring Lithia The tour started nicely through the new area Hafencity but then continued to the area under development and a very desolate district of Hamburg. Compromised Family Coping False -Take initial vital signs (room air Pulse Ox) Swallowing: Intact Dysphagia Aspiration Precautions Safety Ms. Getts is now complaining of sudden sharp, substernal chest pain, very short of breath and is profusely diaphoretic. Sa fortune s lve 10 000,00 euros mensuels Scenario 5 Listen to patient concerns Grieving: False Attain fluids/fiber diet and assisted ambulation Dr. Altace, Educational Needs Increased acuity Scenario 2 You now arrive in the recovery unit one hour post-surgery and you are told that the surgery went well. Skin warm and dry, all vital signs in WNL Bleeding False The cycle of freezing and thawing damages the abnormal cells. Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. Your coworkers are asking you questions about Mr. Dominec. Pain = 2 Shock, Risk for: False Scenario 3 Scenario 5 Report and document results Call Rapid Response protocol initiated It is now third day post-op, the order is for Ms. Cumble to stand by bedside on both legs for 5 minutes, three times a day. -Reinforce the risk if patient has not been NPO and ask the patient when the last time they ate. Don Personal Protective Equipment Educate patient regarding condition Sit at an eye level. GI WNL. Peripheral Neurovascular Dysfunction True. He tells the nurse he has called his wife and wants to be discharged now. Fall Risk Increased acuity No Known allergies (NKA). -Explain that Docetaxel is a hormone therapy that suppresses the testosterone that your testicles produce producing similar results as surgical intervention. Senario 2 His partner is at the bedside asking, "how much longer will he have to wait until taken to surgery?" Report to charge nurse/ head nurse the need for staff education. Allow family to remain Acute Confusion: True Viola Cumble No He is a local TV news reporter that was filming an event at the county fair when there was an explosion. 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. Impaired Mobility True Health Change Increased acuity Document findings/results, Ann Rails, 38 years old, c/o back pain, non-significant past medical history. Check surgical consent for correct procedure and make sure operative site in marked. He replies, "six times in the past four hours". -Tell the wife that you will speak to the husband, and this is apprehension is expected with this surgery/diagnosis. Isolative, appears fearful, crying, and refusing to see her husband. His coughing, to clear his airway, appears ineffective. Educate patient regarding changes to POC Deficient Diversional Activity False Consult Social Service Educational Needs Increased acuity His difficulty voiding finally motivated him to seek care. Kathy Gestalt 20ga. Full assessment #1: _________, No -Evaluate patient's understanding of teaching -Instruct Mr. Burgundy and his cameraman to stop immediately Use therapeutic communication/Active Listening IV Assessment/ N/A Verify call light/bed safety precautions Scenario 4 He also states he is feeling weak. Generalized weakness, blood tinged urine and severe pain upon urination, GI- n/v. Contact Social Services Cryotherapy, which uses an endoscope to apply a cold liquid or gas to abnormal cells in the esophagus. Encourage Mr. Dominec to discuss with his partner his best treatment options. Last Bowel Movement: Date: _____________________ Constipation Diarrhea/Loose Other: Scenario 2 Amount:________ His CP is 7/10 and his BP is 165/96, P 92, R 18, SaO2 98 on 2L NC. Perform pain re-assessment Evaluate outcome of dietary plan Tunneled, site _______________ Implanted port, accessed _____________________ Scenario #3. Apical Pulse Rate: Heart Sounds: Normal S 1 S 2 S 3 Scenario 3 Toileting, Medications List/Times of Medications/Routes of medication, Neurological Assessment Cardiovascular has pacer with rate of 82bpm on demand. Upon entering the room, the patient appears to be trying to get out of bed -Explain to the patient that he is now considered stable, you are taking him to the hallway, and he will be admitted to an impatient room within a few hours Nausea/Vomiting: Yes No Electrolyte Imbalance True Where is my camera man!! Wash and glove hands They wanted to know and pressure you for the information. Notify doctor Provide comfort and pain measures He is questioning the nurse as to why he has been admitted for heartburn. SANE nurse to make second visit today. Disturbed Sensory Perception False -Restart the IV and draw CBC His orthostasis is normalized after a second liter of NS was administered. Notify family Evaluate understanding. No weight bearing today. Cardiovascular has pacer with rate of 82bpm on demand. Upon entering the room, you find Ms. Rails sleeping. : an American History (Eric Foner), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Hx of dementia, from nursing home, fall one day ago. Diet as tolerated. Scenario 4 Ms. Getts is being transferred as an emergency to Critical Care. Scenario 3 Imbalance nutrition: True Respiratory Effort: Relaxed, Regular, Non-labored Pursed lip breathing Labored 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. 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 Regardez le Salaire Mensuel de Nba 2k23 Pc Review en temps rel. Education of Foley Cath Procedure Safety Regular diet. The cells are allowed to warm up and then are frozen again. Administer antipyretic meds Health Change Increased acuity -Explain procedure to the patient Procedure is canceled for the day and rescheduled later allowing for new consent. Our Swift River Simulations are designed to help students and practicing nurses master their skills of Prioritization, Delegation, and Sequential thinkingwithout the requirement of being onsiteor even having to download software. Sa fortune s lve 2 216,00 euros mensuels -Remove the dinner tray and make sure the diet is soft food. -Perform neuro assess IV maintenance fluids with D5 1/4 NS @ 150 ml/hr X 3 then reduce rate to 75 ml/hr. Place pt on PCA pump Vital assessment Day 2 admission, Thomas Richardson is complaining of severe pain and is now begging you for some relief; states pain scale 10/10. Scenario 3 **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 . Mr. Sturgess is recently dx w/ metastatic cancer of colon and he and his family have chosen only Mr. Burgundy now has his cameraman filming in the ED and is attempting to do a live report. -Ensure the bed is in lowest position, the side rails are up, the call light is in reach, and ask the patient if they need anything before you leave the room Diet as tolerated, up ad lib after gait training. Raspberry and Cream Cheese Stuffed Blueberry French Toast with Ozery. Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. Pulse Ox: ___________ % on ____________FiO2; Room Air; Delivery Device Pain Level Increased acuity 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. Obtain recent chest X-ray reports and recent ABG's for physician to review Because of the fall the provider has recommended that he stay in the hospital another night. Mr. Dominec has a male partner and has been married for the past ten years and share their three children to the marriage. Robert Domenic Obtain translator Notify housekeeping. Senario 2 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. ADA diet, intake 25%. Grieving True Bleeding Risk for: False Strict I&O, regular diet, intake 50%. Bowel Movement Total: x________________, Hygiene Times The nurse was told by the gastroenterology nurse that they really struggled before they called anesthesia and they may have caused an esophageal abrasion. Senario 4 Chronic Sorrow False 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! -Inform patient to not get out of bed without assistance and place call light in reach Mr. Gonzales H/H is 12.7/38. Waist belt restraint PRN; family sitter at bedside, assist with bath. Fall, Risk for True Crutches at bedside adjusted for height. -Reassess patient's physical status prior to leaving him in the hallway Continue.Robert Sturgess Room 305 Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. Temp Health Change: Increased acuity Respiratory Rate: WNL Tachypnea Bradypnea Imbalanced Nutrition True 2Provide comfort in pre-surgical room Mr. Dominec. Oral Mucosa: Tongue: Teeth: Offer nutrition/toilet Virginia Smith -Draw a repeat CBC per HCP order to determine current Hemoglobin status -Call security for assistance and compliance officer Fall Risk: Increased acuity Awaiting diagnostic labs. Tube Feeding: Type:_________________________ Amount/Rate: ________________________ Bolus/Infusion Stoma: N/A Colostomy Ileostomy Effluent Consistency: Carotid:____ + Bilateral Other: _____________ RUE: Non-pitting Pitting ___+ Blood, Glucose 185, 4 units of insulin sliding scale for coverage. Needs frequent reminding due to determination to do things herself without assistance. Ineffective airway clearance True Today's weight 226. Palliative care. What order are you providing the information to the receiving nurse? Nausea: False Impaired Mobility False student name date: nur 113 assessment swift river patient: robert sturgess handoff robert sturgess, 81 years old, metastatic ca of colon, hx of diabetes. Use therapeutic communication/Active Listening Full assessment of patient. Palliative care. and the GI cocktail given in the ER did relieve his CP but not completely. Upon entering the room, you find Mr. Sturgess is quiet, appears tense and rigid but states, Provide information for MD to call family at home and explain what has just happened Leave to break room and not continue in conversation. Skin warm dry, bruises on forehead with small laceration. The nurse arrives and sees a tent is being erected as a triage area, and ambulances are lined up delivering trauma patients. References; Access My Virtual Clinicals; Medical-Surgical. Insertion Site: Dry/Intact Redness/Erythema Drainage Tenderness Maceration Assess intake and output and possible reasoning Use therapeutic communication/active listening
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