20ga. Verify Call Light/Bed Safety precautions Skin moist, respiratory bilateral wheezes and rhonchi. Scenario 5 Safety- Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Decisional Conflict True -Obtain chest tube tray and set-up pleurovac Vital signs -Temp 98.2, BP 94/60, P72, RR 22, SaO2 99%. Acute Pain True Flexes & withdraws = 4 -Discuss effectiveness of sitter The patient has been scheduled for an EGD today and has an order for Omeprazole (Prilosec) and Carafate (sucralfate). The nest morning the gastroenterologist informs Mr. Gonzalez that his EGD confirmed a diagnosis of Barrett's esophagus with Dysplasia. The nurse identifies self to the nurse triaging patients and is directed to trauma room 4. Vital assessment Remind the nursing staff that the patient is NPO. He also complains that his throat is still very sore. Imbalanced Nutrition False Employ therapeutic communication: present reality Vital signs Temp 99.4, BP 106/72, P 96, RR 20, SaO2 91%. Hopelessness False. Temperature spiked during the night to 102.4, BP now 146/94 which is slightly elevated, respirations at 30 bpm and slightly labored, heart rate 102 versus 84 from last night shift. Evaluation patient after consult IV Assessment/ N/A Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. Mrs. Pittmon states she has had numbness for years but "now I can't . -Give NS liter bolus However, he quit three years ago when he remarried; he and his wife have a nine-month-old baby. Emergency intubation and assisted breathing is provided for Mr. Thomason Document findings Peripheral Neurovascular Dysfunction False Mr. Dominec is waiting for his partner to arrive to take him home and you notice he has a dry unproductive cough and trouble splinting with a pillow at his operative site. Wash and glove hands -Reassess patient Full assessment including both lying/standing Scenario 2 -Ensure patient privacy and call for help and assist patient to bed once help arrives Educational Needs Increased acuity Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. Tom Richardson, 46yr-old. The cells are allowed to warm up and then are frozen again. Scenario 4 Sensorium Increased acuity, Physiological Today's weight 226. Notify family as to when they may come and visit. His wife tells the nurse that he seemed very distant and did not want to talk much. Breath Sounds: Clear bilaterally. Noncompliance False Palliative care. Paul Greer Decreased Cardiac/perfusion: False Skin warm and dry, may sit up on edge of bed today. Chronic Confusion False All our products can be personalised to the highest standards to carry your message or logo. Ronald Burgundy Document and prepare to transfer to Surgical ICU -Tell the wife that you will speak to the husband, and this is apprehension is expected with this surgery/diagnosis. 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. Robert Sturgess - Swift River Swift River University Nightingale College Course Concepts of Nursing I (BSN 246) Academic year2022/2023 Helpful? Clear liquid diet. His VS are BP 122/64, P 89, R 12, SpO2 93%. No known allergies (NKA). -Reapply the NC that he was admitted with at 2L Scenario 1 Stools are decreasing but patient remains very weak. Explain that he will probably not be going home at least until his doctor sees him. -Inform patient to not get out of bed without assistance and place call light in reach Give verbal report Impaired Gas Exchange True Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. Evaluate understanding Fall, Risk for True Begin post op education for day one 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! Administer antipyretic meds 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. When the nurse enters the room later that day to inform him that the procedure is scheduled for 1430, they see Mr. Gonzalez is sitting in front of a lunch tray. Inform and educate spouse of dietary orders Evaluate patient understanding Bladder distention Pelvic pain Low back/flank pain Vital signs -BP 124/82, Temp 98.2, P 84, RR 22, SaO2 96%. Scenario 1 Shock, Risk for: False Scenario 4 Patient and family upset regarding dx. Deficient Fluid Volume True Remain with patient and reassure Document results and findings Nausea False Report to charge nurse/ head nurse the need for staff education. Temp Esteem Infection, Risk for True Therapeutic communication. Stat lithotripsy treatment ordered. Scenario 4 Mr. Burgundy has quieted down, and the fentanyl has apparently alleviated most of his pain and anxiety. Pain Level: Increased acuity Mr. Mancia is non-English speaking patient and is fearful of being discovered as an illegal immigrant. Sarah Getts Sleep Deprivation False. Pain affecting: N/A Sleep Activity Exercise Relationships Appetite Concentration Needs frequent reminding due to determination to do things herself without assistance. Scenario 2 Allow for non-compliance of request Scenario 3 Scenario #3. Grieving: False. -Assess patient's understanding of the teaching and discuss home support, os de la main et de la ceinture pelvienne, Julie S Snyder, Linda Lilley, Shelly Collins. jasmine . Cough: Evaluate understanding The patient is asking you where her son is, the last place she saw him was right before the explosion. Senario 5 Scenario 3 Mr. Greer has just returned from surgery. No known allergies (NKA). Check input/output for possible dehydration Neuro WNL, alert, and cooperative but worried about scarring and is reluctance regarding walking on leg. Retrieve cast removal tool Yes Productive Non-productive Describe Sputum: _______________________ Peripheral Neurovascular Dysfunction False. Mr. Dominec leaves the room and you discharge him and escort him and his partner to the car. Suprapubic Insertion site: WNL S/S Infection : ____________________ He is a local TV news reporter that was filming an event at the county fair when there was an explosion. Scenario 1 Wash hands You correctly diagnosed 11 out of 16 options. Esteem Impaired comfort: True Encourage fluids and fiber diet Visual assess Last pain medicine 2hrs ago at 1300(Demerol 50mg/ Zofran 4mg IV). 97.4, Resp 16 and Pulse Ox 94%. Scenario 5 Provide comfort measures Raspberry and Cream Cheese Stuffed Blueberry French Toast with Ozery. Bleeding, Risk for: True Bleeding, Risk for True Vital signs -Temp 99.1, BP 124/62, P 77, RR 20, SaO2 91%. Determine clinical decisions based on listening to an audible client report. 0800 1200 -Tell the patient that they are being admitted to r/o any cardiac issues ADA diet, intake 25%. Toggle navigation Swift River. Ms. Gestalt is now complaining of fever and chills. Full head to toe neuro assessment. How was this except 115 pulse, which is normal for him. Dx- urinary stones with 3 episodes/5yrs. Apply restraint Safety Senario 4 Pain and numbness in legs for one week. Grieving: True Compromised Family Coping False -Reinforce to the patient to not get out of bed -Complete head-to-toe assessment while patient is on the floor. Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma. After washing and gloving hands, you then identify yourself and the patient, Ann Rails. Offer nutrition/toilet Educate patient regarding condition Tibial: _____ + Bilateral Other: ______________ Generalized: Pedal: ______ + Bilateral Other: ____________ Sacrum: Non-pitting Pitting ___ +. Consult Social Service Ineffective Peripheral Tissue Perfusion False Scenario 4 Scenario 3 -Set-up for stat portable chest x-ray Scenario 5 Assess for bowel sounds Ineffective airway clearance True Educate patient 50% intake. Dr. Anderson, Educational Needs Increased acuity Scenario 3 GI WNL. Assign nursing diagnosis and plan the appropriate intervention and evaluate outcomes while working through time pressure and distractions, including random call light requests. Ms. Getts is requesting water to drink. Where is my camera man!! Decreased cardio tissue perfusion: False Diet as tolerated. 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! References; Access My Virtual Clinicals; Medical-Surgical. No known allergies (NKA). The dinner tray is waiting for the patient in his room, and the nurse notices it is a regular diet. Mrs. Smith shares with you that even though she signed the operative consent she was not sure if this was the right surgical procedure for her. Nausea: False Escort patient Fall, risk for: True Scenario 4 Tap patient and ask, "Are you okay?" Neuro WNL alert and cooperative. : an American History, EMT Basic Final Exam Study Guide - Google Docs, Philippine Politics and Governance W1 _ Grade 11/12 Modules SY. Pulses: Strength & Symmetry Edema: Scenario 4 Ms. Cumble states that she has not had a BM for three days. You enter patient's room. Vital Signs: B: 160/92, P: 96, R: 22, SpO2: 98, T: 98.9F, 37.1C. Water/Flush: Imbalanced Nutrition: True RLE: ______________ LLE: _____________ Mr. Wright is pleasant and cooperative, but needs to be reminded to avoid pressure on his heel and sacrum. Activity as tolerated with assistance. 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. Safety- Also worth mentioning is the 'Alter Schwede' - a 217t . The patient describes this pain as a heavy pressure with intermittent stabbing. Urine Color: Clarity: Odor: Document results/findings Viola Cumble She has received a dose of Hydrocodone for PRN pain 20 minutes ago. Stoma Status: Pink-Red/Moist Dusky Retracted Excessive bulging Deficient Knowledge False Full assessment Robert Strurgess Mrs. Smith's surgery has now ended. Respiratory Rate: WNL Tachypnea Bradypnea Impaired Gas Exchange True Educate patient Safety Educate patient regarding changes to POC Hx of dementia, from nursing home, fall one day ago. Senario 1 Toileting, Medications List/Times of Medications/Routes of medication, Neurological Assessment Adjust crutches Senario 3 Eye opening Spontaneous = 4 Assess Acute Confusion True Scenario 5 -Ask Mr. Burgundy to lower his tone as it can be disturbing to other patients Two hours later, Mr. Duncan is asked how frequent his stools have been today. VS: BP 158/90, HR 89, R 18, T 97.8 F. Impaired Mobility, Risk for True Grieving True 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. He does not want to return to the nursing home, and does not wish to burden or live with his children. Encourage fluids Upon assessment, you determined that she is confused to person, time, and place but is easily directable. -Discuss with sitter that patient needs continual observation Dr. Donofrio, Physiological Psychological Needs: Increased acuity -Check on patient/sitter hourly Scenario 1 Use therapeutic communication/Active Listening IV maintenance fluids with D5 1/4 NS @ 150 ml/hr X 3 then reduce rate to 75 ml/hr. Disturbed Body Image True The patient states that the symptoms occurred in the middle of the night and woke him from his sleep. Excess Fluid Volume, Risk for False You enter his room and recognize that Mr. Thomason appears to be talking to himself and appears confused. -Advise patient not to get up and walk on his own Dr. Rondeau, Educational Needs Increased acuity Apply nasal cannula Safety Increased acuity, Physiological After two hours, Mr. Dominec is alert and cooperative, nauseated and concerned about impending surgery this evening. Mr. Greer is on the floor still but is awake and oriented and is complaining of back pain below his right scapula. It is unclear if he lost consciousness. Scenario 2 Esteem -Assess if the contents of lunch tray are intact. Scenario 5 The patient is being prepared for discharge and his IV has been removed. Scenario 1 Psychological Needs Increased acuity Respirations 1. Scenario 3 Full assessment Urinary Catheter: N/A Indwelling Short-term Indwelling Long-term Date of Insertion:________ Size: _____F Verify call light/bed safety precautions SANE nurse to make second visit today. Apply fall risk bracelet Scenario 2 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. Sitting, BP 109/60, P 114, Standing the patient becomes very lightheaded and the nurse has them lay back down. LUE: Non-pitting Pitting ___+ Safety Scenario 3 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. The Swift River is one of the most unique and popular trout fishing destinations in Massachusetts, yet the dynamics of this exceptional fishery have not been well understood. Evaluate caller understanding She is with her physician. Mr. Richardson is requesting assistance to ambulate to bathroom. Educate patient Scenario 4 Linen Change Radiofrequency ablation, which uses heat to remove abnormal esophagus tissue. Perform pain reassessment Scenario 5 Scenario 4 Perform full assessment and provide anti-nausea medicine. Acute Pain True Senario 3 -Medicate for pain Document Results, Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. Obtain recent chest X-ray reports and recent ABG's for physician to review Verify call Light/bed safety precautions Upon entering the room, you find Ms. Rails sleeping. Provide emesis basin/cloth Scenario 4 Use therapeutic communication/Active Listening He is emotionally distraught and is insisting that he be allowed to report what is going on from the ER. Wife at bedside. Deficient knowledge: True Aggravating Factors: Scenario 3 Reassure patient and help explain any new orders from physician to patient