Assessment of bowel movement Biopsies were sent to determine the treatment. Diet as tolerated, up ad lib after gait training. Don Personal Protective Equipment Safety In the interim, start an IV and start infusing Ringers Lactate. Fall Risk: Increased acuity Esteem His orthostasis is normalized after a second liter of NS was administered. Educate patient Scenario 1 Reassure patient and help explain any new orders from physician to patient Provide comfort in pre-surgical room Mr. Dominec. Oriented to: Person Place Time Retrieve cast removal tool Explain to her family and provide contact information. Chronic Confusion False Scenario 5 The patient is awake, alert, and oriented. Strict I&O, regular diet, intake 50%. You have them remain with you, seated in comfortable place, while you call ICU and attempt to locate physician for them. Bowel sounds: Active, Hyperactive, Hypoactive, Absent (listen for full 5 minutes) Scenario 1 She is also investigating bone marrow transplantation. Document results Scenario 2 Evaluate/Modify Mobility Plan, Carlos Mancia, 48yr-old, Spanish speaking migrant worker with no known past medical Hx. Increased fall risk. Pain Level Normal acuity Regardez le Salaire Mensuel de Nba 2k23 Pc Review en temps rel. Scenario 1 Scenario 1 Wash hands RUE: ______________ LUE: _____________ BP 154/89, P 94 F, R 22, T 98.3F, SaO2 95% on room air. Visual assessment Employ therapeutic communication: present reality Remain with patient and reassure Read PT report Impaired Comfort True Combien gagne t il d argent ? Senario 1 Evaluate patient learning Decreased Cardiac/perfusion: False Patient and family upset regarding dx. Diet as tolerated. They wanted to know and pressure you for the information. Suprapubic Insertion site: WNL S/S Infection : ____________________ Adjust crutches Ineffective Peripheral Tissue Perfusion False -Complete full assessment, to include neuro -Begin q15 minute neuro checks Scenario 2 Ms. Gestalt is now complaining of fever and chills. Allow husband to come into recovery for a quick one-minute visit. Scenario 4 Impaired Skin Integrity, Risk for True Visual assess Monitor and evaluate fluid intake You discuss this cough with Mr. Dominec to determine how long he has had it. Stoma status: Pink-Red/Moist Dusky Retracted Excessive bulging Pain Level Increased acuity Scenario 1 Perform circulatory evaluation Mr. Gonzalez has been admitted to the floor to determine that his chest pain is not related to a cardiac event. You enter room one hour after the physician has left the patient. Other: _______________________________ Explain reason for assessment and procedure Document results. Pain re-assessment Start secondary large bore IV line Continue.Robert Sturgess Room 305 Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. 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 -Medicate for pain Sleep Deprivation False Wash and glove hands Teach Cameron. Inspect cast site Scenario 5 The lesion was identified as Kaposi's Sarcoma. Document results, Care of the Patient with a Cardiovascular or, NCLEX - Care of Patient with an Immune Disord, Quiz: Chapter 54, Care of the Patient with an, Chapter 54: Care of the Patient with an Immun, Chapter 17, Section 5; Providing First Aid fo. Scenario 3 You are the now the Surgical ICU nurse assigned to her. Neuro WNL alert and cooperative. Fall, risk for: True Deficient Knowledge False Linen Change -Contact HCP to determine when they are available to speak with the patient Wash and glove hands Nursing questions and answers. Scenario #3. Love and belonging Hep-Lock in place left AC. Scenario 3 Inform patient about the progression and risk a PCP infection has for a patient with AIDS. Scenario 4 Mr. Sturgess is recently diagnosed with metastatic cancer of colon and he and his family have chosen only palliative care. You are concerned about preventing the patient from falling. Also worth mentioning is the 'Alter Schwede' - a 217t . Stay with patient for surgeon's arrival to explain intended surgical procedure Explain to physician what interventions you have recently initiated Verify call light/bed safety precautions Gait: ______________________________, Skin Integrity Assessment Assist patient -Ensure patient privacy and call for help and assist patient to bed once help arrives Notify lead nurse/doctor No known allergies (NKA). He chooses to go home and see the doctor tomorrow in his office. He warns the patient that if he does not comply with the treatment and preventive measures, he will need other treatments that may include. -Attempt to orient to person, place, and time Temperature is 98.3, HR is 87, RR is16, BP is 121/74, PaO2 is 98%. Next time we'll spend our 60 on some food and nice beers. Bladder distention Pelvic pain Low back/flank pain You, his prior nurse, notice the family and respond to them. Inappropriate words = 3 Verify call light/ bed safety precautions It was diagnosed by a portable X-ray and quickly splinted by the ER staff. We have more than 20 years' experience in the industry providing a quality service to our clients We pride ourselves on our customer-orientated service and commitment to delivering high end quality goods within quick turnaround times. Upon entering the room with a translator to admit him to the hospital, he is asked for address and phone number but refuses to comply. 3. Educate patient He also states he is feeling weak. Safety Mr. Dominec has a male partner and has been married for the past ten years and share their three children to the marriage. Mr. Richardson is requesting assistance to ambulate to bathroom. Abdominal Pain: Non-tender Tender/Pain Describe: Esteem Senario 5 Validate NPO Status His VS are BP 122/64, P 89, R 12, SpO2 93%. Toggle navigation Swift River. Impaired Skin Integrity, False Senario 1 Esteem Scenario 1 Then the bus splashed into the river for a cruise. Your Swift River Virtual Clinicals account has been linked to your ATI Student account. Regardez le Salaire Mensuel de Ubah Kalimat Efektif Online en temps rel. Encourage to ambulate with assistance to void if needed The charge nurse tells you not to move the patient, because there is no special treatment according to social status. -Assess patient LOC, by walking patient and asking them to take deep breaths. His difficulty voiding finally motivated him to seek care. Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. She has just been transported from recovery. -Inform Mr. Burgundy that he cannot report from the ED, as patient privacy is strictly protected by HIPPA -Complete incident report. Needs frequent reminding due to determination to do things herself without assistance. -When the HCP arrives, stay in the room to determine whether you can continue care with the patient Anxiety True Senario 2 Bowel Movement Total: x________________, Hygiene Times Esteem ADA diet, intake 25%. Vital Signs: B: 160/92, P: 96, R: 22, SpO2: 98, T: 98.9F, 37.1C. Continent: Yes No Brief/Diaper Scenario 5 Encourage fluids/fiber/ambulation -Transport Mr. Burgundy to his room Her husband who is present states, "I thought it was just a lumpectomy she was having this morning." Evaluate learning Allow for non-compliance of request Document results Do not disturb He has been taking his HIV medication daily. Ms. Getts is requesting water to drink. -If cardiac is suspected call the provider and the rapid response team. Document findings/results, Ann Rails, 38 years old, c/o back pain, non-significant past medical history. is a 57 y/o who has been admitted for a radical prostatectomy. Rapid Response team arrived including anesthesia. Day 2 admission, Thomas Richardson is complaining of severe pain and is now begging you for some relief; states pain scale 10/10. She has been documented as being obese, new onset. Wash and glove hands Scenario 4 IV NS is started, and lab work is sent. Educate pt regarding changes to POC Deficient Fluid Volume True #1: _________, No Obtain translatorT Waist belt restraint PRN; family sitter at bedside, assist with bath. Blood Glucose 185, 4 units of insulin sliding scale for coverage. Now, meeting the CDC definition, he has full blown AIDS but is asymptomatic at this time. Scenario 5 Scenario 1 Chronic Pain False Evaluation patient after consult Reassure patient of options Senario 2 Spiritual Distress False. Clinical 2. Description: Sharp Stabbing Throbbing Aching Cramping Other: Educate patient Wash and glove hands Refer call to contact health department Sexuality: True. Scenario 5 The dinner tray is waiting for the patient in his room, and the nurse notices it is a regular diet. Check monitor -Continue to observe urine for hematuria and document findings Self-Care Deficit False No known allergies (NKA). Excess Fluid Volume, Risk for False Dr. Levine, Marcella Como, 38 yr-old, Sexual Trauma Victim (Rape), unknown assailant. Too bad the cruise area was a very unatractive part of the River Elbe. The patient asks the nurse to explain about these medications and why they are in such a hurry. -Explain to Mr. Burgundy that space in the ED is allocated based off of patient need Opening Title Production company Cast and crew Genre J A N U A R Y 2: The Killing of John Lennon: IFC First Take: Andrew Piddington (director/screenplay); Jonas Ball, Krisha Fairchild, Gunter Stern, Gail Kay Bell, Mie Omori, Robert C. Kirk: Crime, Drama: 4: One Missed Call: Warner Bros. Pictures / Alcon Entertainment / Kadokawa Pictures: Eric Valette (director); Andrew Klavan (screenplay . Talk with her stating surgery is over and she did great. Remain with patient Iron forms a sulfide with the approximate formula Fe7S8\mathrm{Fe}_7 \mathrm{~S}_8Fe7S8. Hopelessness True PT to educate patient The patient has a Foley catheter in place and is reporting 8/10 incisional pain and he is asking why his throat is sore. -Notify HCP of fall, complete incident report Your response to all of them would be: Scenario 1 Palliative care. Determine clinical decisions based on listening to an audible client report. Mr. Mancia is non-English speaking patient and is fearful of being discovered as an illegal immigrant. Need frequent reminder to stay in room and maintain mask precautions. Reasses temp in 1 hour. The sister of Mr. Mancia calls from home to speak with you. Stat lithotripsy treatment ordered. -Tell the patient that they are being admitted to r/o any cardiac issues Obtain translator Electrolyte Imbalance False Attain fluids/fiber diet and assisted ambulation Scenario 2 Sit at an eye level. Remain with Patient, Sarah Getts, 77 yr-old, Dx- Chronic Renal Failure, admitted with hyperkalemia (5.9, Eq/L)/hyponatremia (128mEq/L). Scenario 4 -Reapply the NC that he was admitted with at 2L Self-Care Deficit True Nausea False Chronic Pain False Verify Call Light/Bed Safety precautions When the HCP realizes who he is, he tells the nurse to move the patient in the treatment room down the hall and put Mr. Burgundy in there. However, he quit three years ago when he remarried; he and his wife have a nine-month-old baby. IV maintenance fluids with D5 1/4 NS @ 150 ml/hr X 3 then reduce rate to 75 ml/hr. Fear True The patient tells the nurse that yesterday he was, "concerned about having an erection, and now they want to cut off my testicels". 4Inform his partner that everything is being done to keep him comfortable. Nutrition True Document and provide copy for Mr. Dominec to share with his follow up appointment tomorrow. Assess Senario 1 Wash and glove hands Scenario 4 -Reorient Patient to person, place, & time Scenario 5 -Ensure there is a full O2 tank on the gurney, place patient on Nasal Cannula She receives the pre-op medication. Evaluate understanding : 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. You also notice the patient is more difficult to orient. -If gastric reflux is suspected administer PRN antacids (GI cocktail) Alert and cooperative. Ambulates with minimal assistance. Evaluate understanding Psychological Needs Normal acuity Wash and glove hands Today's incentive spirometry Tidal Volume is 1250ml, improvement over yesterday's 900ml. Mr. Duncan is now complaining of feeling "dizzy" when he stands. He is experiencing new onset of shortness of breath and has a nasal cannula with 2L of Oxygen in place. Neptune is an average distance of 4.5109km4.5 \times 10^{9} \mathrm{km}4.5109km from the Sun. -Reinforce to the patient to not get out of bed A GI cocktail was administered, and the patient stated that it decreased his pain to a 6/10. Wash and glove hands Safety He is questioning the nurse as to why he has been admitted for heartburn. Sa fortune s lve 1 900,00 euros mensuels Her husband and children remain with her in the surgical holding area awaiting transport to the OR. Scenario 4 -Check on patient/sitter hourly Place pt on PCA pump Tunneled, site _______________ Implanted port, accessed _____________________ Perineal Care Purposive Communication Module 2, Chapter 1 - Summary Give Me Liberty! Explain that he will probably not be going home at least until his doctor sees him. Scenario 1 Scenario 1 Fall, risk for: False Neuro WNL alert and cooperative. Report this activity immediately to the hospital privacy officer Administer pain medications Document conversation He has been ruled out for an MI. Encourage Mr. Dominec to discuss with his partner his best treatment options. You explain that he is receiving a higher level of care and was he was sedated before leaving the floor to make him more comfortable. Pain affecting: N/A Sleep Activity Exercise Relationships Appetite Concentration Disturbed Body Image True Scenario 1 Ineffective airway clearance True Fall, Risk for True 20ga. Regardez le Salaire Mensuel de Tthuchicago Org en temps rel. Fall Risk Increased acuity Insert Foley catheter Acute Confusion 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. He is emotionally distraught, and is insisting that he be allowed to report what is going on from the ED. Impaired Urinary Elimination True Regardez le Salaire Mensuel de Ticketmaster Beyonce Koln en temps rel. Skin Color: Consistent with ethnicity pinkish-tan light-tan dark-tan light-brown dark-brown 97.4, Resp 16 and Pulse Ox 94%. Compromised Family Coping False The tour started nicely through the new area Hafencity but then continued to the area under development and a very desolate district of Hamburg. Scenario 1 Insertion site: Dry/Intact Redness Tenderness/Pain Warmth Coolness Swelling Drainage Scenario 4 Nausea False Document results Scenario 4 Elevate head of bed Radiofrequency ablation, which uses heat to remove abnormal esophagus tissue. Connect telemetry -Verify that discharge orders have been written, provide discharge instructions, and in inform provider about the chest pain. Because of the fall the provider has recommended that he stay in the hospital another night. Scenario 3 Ronald Burgundy Remind the nursing staff that the patient is NPO. Senario 1 IV fluids of D5 1/2 NS are infusing at 100 mL/hour to his right forearm. Acute Confusion True Social worker with patient this morning. Robert Strurgess His partner is not with him at this time but will arrive soon to facilitate his discharge home. Scenario 2: 1Educate about recovery from appendectomy and care to wound. Amount:________ Imbalance nutrition: True -Ask the patient if it is okay to discuss his care in front of his children. Vital Assessment Senario 2 Safety Increased acuity, Physiological Remind physician to wash his hands before examining the patient Administer antipyretic medication Electrolyte Imbalance, Risk for True 20ga. She is also to receive radiation, chemotherapy, and hormone therapy post operatively. 2Provide comfort in pre-surgical room Mr. Dominec.
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