Blood, Glucose 185, 4 units of insulin sliding scale for coverage. Tom Richardson Scenario 3 Vital signs -Temp 98.8, BP 102/76, P 102- irregular, RR 22, SaO2 90%, cardiovascular on telemetry with Sinus irregular rhythm. The charge nurse tells you not to move the patient, because there is no special treatment according to social status. Elevate head of bed Deficient Knowledge True Impaired Urinary Elimination True Gastrointestinal Assessment Wash and glove hands -Tell the wife that you will speak to the husband, and this is apprehension is expected with this surgery/diagnosis. Scenario 2 He is emotionally distraught and is insisting that he be allowed to report what is going on from the ER. Scenario 2 You arrive in room to find Ms. Monson talking to herself. Ineffective Renal Perfusion, Risk for True Mr. Richardson is requesting assistance to ambulate to bathroom. Oriented to: Person Place Time The MD on site makes the decision to intubate the patient and start ventilatory assistance and move the patient to Respiratory Intensive Care. Linen Change Skin Color: Consistent with ethnicity pinkish-tan light-tan dark-tan light-brown dark-brown Scenario 3 Impaired Home Maintenance management r/t client or family False The oncologist is insistent that the treatment begin immediately. Escort patient Tubes: None Salem Sump Nasoduodenal PEG J-Tube pH: ______ IV D5 1/2 NS @150ml/hr. -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 It is unclear if he lost consciousness. Scenario 4 Family arrive one hour after event to his prior room and find Mr. Thomason's room is empty and have no idea of the events that have just occurred. Respiratory Rhythm: Regular Rhythmic Irregular Periods of Apnea Cheyne-Stokes Infection, risk for: False. NPO with small amount of ice chips only. Constipation, risk for: True Scenario 5 jasmine . You arrive in room to check on her, after washing hands. Inform and educate spouse of dietary orders -Complete full assessment, to include neuro : an American History, EMT Basic Final Exam Study Guide - Google Docs, Philippine Politics and Governance W1 _ Grade 11/12 Modules SY. Scenario 2 Mrs. Stukes is feeling nauseated. -Assess if the contents of lunch tray are intact. Evaluate understanding He has a history of well controlled GERD with over-the-counter Tagamet (Cimetidine), and Tums. Paul Greer Now, third day post-op, Mrs. Stukes appears sad and depressed upon entering the room. Begin post op education for day one Fall, Risk for True Dyspnea at rest Dyspnea with minimal activity Use of accessory muscles He is complaining of pain in his left arm, and pain in his left chest when he tries to take a deep breath. The nurse was told by the gastroenterology nurse that they really struggled before they called anesthesia and they may have caused an esophageal abrasion. Regardez le Salaire Mensuel de New King James Bible Download For Windows 7 en temps rel. Ineffective Coping False Awaiting transport. Dr. Brown, Educational Needs Increased acuity Next time we'll spend our 60 on some food and nice beers. Sleep Deprivation False Reassure patient of options Offer masks to visitors Scenario #3. No BP 154/89, P 94 F, R 22, T 98.3F, SaO2 95% on room air. Widespread Color Change: N/A pallor cyanosis jaundice erythema You now arrive in the recovery unit one hour post-surgery and you are told that the surgery went well. Vital signs -Temp 98.4,BP 178/105, P 112, RR 28, SaO2 94%; Neuro- WNL's. Anxiety True #ozerysnackingrounds I am so excited to be partnering with Ozery Family Bakery today. -Verify that discharge orders have been written, provide discharge instructions, and in inform provider about the chest pain. Flexes & withdraws = 4 Apical Pulse Rate: Heart Sounds: Normal S 1 S 2 S 3 Shock False Scenario 5 Remain with Patient, Sarah Getts, 77 yr-old, Dx- Chronic Renal Failure, admitted with hyperkalemia (5.9, Eq/L)/hyponatremia (128mEq/L). Self-Care Deficit: True RUE: ______________ LUE: _____________ Educational Needs Increased acuity 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. Validate NPO Status Wash and glove hands Deficient Knowledge True Safety Increased acuity, Physiological -Begin q15 minute neuro checks Deficient Knowledge False Upon entering room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." Document results and findings Communication/Speech: Clear Non-verbal Slurred Aphasia Other You are about to call the Surgical ICU and give report. Mr. Dominec decides he does not want to see Infectious Disease doctor about his new cough. Upon entering the room, you find Mr. Sturgess is quiet, appears tense and rigid but states, Scenario 2 Document results Encourage fluids/fiber/ambulation Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma. Assess Re-assess patient You enter patient's room. Senario 5 Senario 5 Today's incentive spirometry Tidal Volume is 1250ml, improvement over yesterday's 900ml. Deficient Fluid Volume True IV maintenance fluids with D5 1/4 NS @ 150 ml/hr X 3 then reduce rate to 75 ml/hr. She has IV access and has received a small dose of Valium to reduce apprehension. Amount:________ Dr. Small at bedside with patient and family. 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. -Explain to the patient that because of his weakness and unknown cardiac status as well as the IV, he is a fall risk and should not get out of bed without assistance. Neck: ______________ Document results/findings He is emotionally distraught, and is insisting that he be allowed to report what is going on from the ED. Toileting, Medications List/Times of Medications/Routes of medication, Neurological Assessment Notify doctor if condition is abnormal The ER nurse reports that his cardiac enzymes were borderline, (Troponin?, CK/CKMB?) Physiological- Why is cysteine such an important amino acid for defining the tertiary structure of some proteins? Discuss follow up with his doctor. Scenario 4 Scenario 1 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. Skin warm and pale. Impaired Skin Integrity, Risk for False fallout 4 save wizard quick codes death and wheel of fortune tarot combination; gambling meaning in english urdu alpine spiced apple cider gluten free; how to use v2ray samsonas sequential gearbox subaru; lg magic remote power light stays on Respiratory Rate: WNL Tachypnea Bradypnea The emergency bathroom light goes off and the nurse finds Mr. Greer on the floor in the bathroom. List the nursing care order. Remain with patient The cells are allowed to warm up and then are frozen again. Spiritual Distress False. -Assess patient LOC, by walking patient and asking them to take deep breaths. Scenario #2. Obtain translatorT Diet as tolerated. Scenario 5 Scenario 3 Esteem Social Isolation, Risk for True Mr. Greer is on the floor still but is awake and oriented and is complaining of back pain below his right scapula. 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. Scenario 2 RLE: ______________ LLE: ______________, Casts/Splits: ____________________________, Motor response Verbal command = 6 Skin integrity at risk True Noncompliance True Imbalanced Nutrition False She is also to receive radiation, chemotherapy, and hormone therapy post operatively. Impaired Skin Integrity, Risk for False Scenario 2 Educate pt regarding changes to POC Nutritional Intake: Adequate Inadequate BMI: Scenario 5 Encourage fluids Water/Flush: -Explain that Docetaxel is a hormone therapy that suppresses the testosterone that your testicles produce producing similar results as surgical intervention. Recent chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes. Combien gagne t il d argent ? No known allergies (NKA). -Use therapeutic communication/active listening Check pedal capillary refill Scenario 4 Senario 4 Scenario 4 Ms. Getts is being transferred as an emergency to Critical Care. Scenario 2 Scenario 5 Pain Level Increased acuity IV fluids of D5 1/2 NS are infusing at 100 mL/hour to his right forearm. Upon entering the room, you find Ms. Rails sleeping. Ms. Gestalt is second day post-op and has requested to get out of bed and to ambulate to bathroom. Administer antiemetic medication His overall health is good, and he has known he has been HIV positive for the past five years. Skin warm and dry, may sit up on edge of bed today. -Instruct Mr. Burgundy and his cameraman to stop immediately Mr. Richardson is now pain free and questioning why he is plagued with recurring urinary stones. It is now two weeks later; Mrs. Smith has returned. You, his prior nurse, notice the family and respond to them. You take his vital signs which are: Temp 101.3, Pulse 88, Resp 24, B/P 116/84. No weight bearing today. You return to the break room on your floor. Insertion site: Dry/Intact Redness Tenderness/Pain Warmth Coolness Swelling Drainage An abc-phase-sequence three-phase balanced wye-connected source supplies power to a balanced wye-connected load. You notify the charge nurse that you have never taken part in inserting a chest tube. Notify charge nurse that discharge will probably not occur today. Fall Risk Increased acuity Perform pain reassessment Therapeutic communicationT Mr. Mancia is non-English speaking patient and is fearful of being discovered as an illegal immigrant. Diet as tolerated, up ad lib after gait training. When she moves him to the hallway, Mr. Burgundy begins yelling at you "Do you know who I am, I demand a room! Grieving: False Full assessment Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Ambulates with minimal assistance. NG tube to low suction possibly D/C'd today after Dr. Levine rounds. Wash and glove hands Recent blood gases demonstrate falling PaO2 (hypoxemia) and increasing CO2 (Hypercapnia). Mr. Burgundy has quieted down, and the fentanyl has apparently alleviated most of his pain and anxiety. Strict I&O, regular diet, intake 50%. Scenario 1 Respirations He also states he is feeling weak. Reasses temp in 1 hour. Educational needs: Increased acuity Senario 2 She has received a dose of Hydrocodone for PRN pain 20 minutes ago. Temperature is now 102.8. 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. DSD (dry sterile dressing), forehead laceration clean and dry intact. -Perform neuro assess 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! Failure to Thrive True. -Start IV 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. Talk with her stating surgery is over and she did great. Scenario 1 Ambulates with assistance. -Check on patient/sitter hourly Senario 2 Palliative care. Dr. Roopes, Estelle Hatcher, 31yr-old, r/o appendicitis, 1st day post-op appendectomy; No known allergies (NKA); Vital signs - Temp 101.2, BP 108/74, P 92, RR 20, SaO2 99%, alert and cooperative. -Explain to Mr. Greer that it may take several days for healing, and he may have temporary incontinence, but it will resolve over time. Ms. Rails shares with you her fear of being discharged home to an abusive husband. How was this Educate patient Urinary Catheter: N/A Indwelling Short-term Indwelling Long-term Date of Insertion:________ Size: _____F Vital signs taken by automatic B/P Cuff q 15 minutes Combien gagne t il d argent ? You escort them with you to the ICU. Scenario 5 When a physician makes an incision into a body cavity just superior to the diaphragm and inferior to the neck, what body cavity will be exposed? The oncologist is recommending Docetaxel as opposed to an orchiectomy. Scenario 3 Explain to physician what interventions you have recently initiated 3Check surgical consent for correct procedure and make sure operative site is marked. 20ga. He also complains that his throat is still very sore. Increased fall risk. Include patient condition change in shift report -Recheck Tilts after the NS bolus is complete.T After 3 hours, Ms. Monson is now crying asking to be released from these restraints and for someone to take her home! Scenario 3 No known allergies (NKA). Scenario 5 Hx of dementia, from nursing home, fall one day ago. Pain, Acute True Record intake and output Family in room with patient very concerned. -Complete incident report. except 115 pulse, which is normal for him. -If cardiac is suspected call the provider and the rapid response team. RLQ: RUQ: LUQ: LLQ: 50% intake. Compromised Family Coping: False The impedance per phase in the load ist 14+j1214+j 12 \Omega14+j12. Mr. Thomason is anxious and is obviously worsened from the shift before in overall condition. Therapeutic communication -Medicate for pain Deficient knowledge: False Safety- Paul Greer Recently he manifested an unusual black lesion on his thigh and developed an opportunistic fungal mouth infection which was treated successfully. Mr. Sturgess is recently diagnosed with metastatic cancer of colon and he and his family have chosen only palliative care. All opinions are mine alone. He chooses to go home and see the doctor tomorrow in his office. Spanish interpreter available at extension 61178. Grieving False Determine from medical record if partner is aware of his recent AIDS diagnosis. Sensorium Normal acuity, Physiological Acute Pain True Escort patient to vehicle Decreased Cardio Tissue Perfusion False Apical pulse rhythm: Regular Irregular Location: The patient tells the nurse that yesterday he was, "concerned about having an erection, and now they want to cut off my testicels". His wife tells the nurse that he seemed very distant and did not want to talk much. His orthostasis is normalized after a second liter of NS was administered. Ineffective Peripheral Tissue Perfusion False Notify doctor 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. Nathaniel Gonzalez Ms. Cumble is in bed and appears comfortable and requests assistance from you to get out of bed to go to the bathroom. Perform pain re-assessment Use therapeutic communication/Active Listening Purposive Communication Module 2, Chapter 1 - Summary Give Me Liberty! Vital sign Temp 98.4, BP 136/78, P 72, RR 20, SaO2 97%. Pain and numbness in legs for one week. school system of the host country and may not know how to choose the programme, Question 34 Correct Mark 100 out of 100 Flag question Question text hr tag, efefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefef, arbitrary parameters a b will be a complete solution of 38 The main problem then, Reduces costs of providing on site office space To individual Makes more time, METHYLXANTHINE DRUGS-Chemistry FinalsExam PrepNotes.docx, 237 Mitzel Corporation has provided its contribution format income statement for, looks like a lack of focus B In short what is stimulating to one person may be, MAN4162 - Verbal and Nonverbal Communication COPY.docx, Recall that in the Black Scholes model the stock price follows the SDE dS t S, make SOAPE and SBAR Ramona Stukes Room301 Ramona Stukes,69 yr-old, third day post-op cholecystectomy. The patient describes this pain as a heavy pressure with intermittent stabbing. Document results Contact Social Services Use therapeutic communication/Active Listening But that's changing. Safety Use therapeutic communication/Active Listening Establish second IV Electrolyte Imbalance False 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. Dr. Anderson, Educational Needs Increased acuity Other: _______________________________ Airborne Isolation. Color:__________ is a 57 y/o who has been admitted for a radical prostatectomy. Temperature is 98.3, HR is 87, RR is16, BP is 121/74, PaO2 is 98%. Senario 5 -Explain to Mr. Burgundy that space in the ED is allocated based off of patient need His CP is 7/10 and his BP is 165/96, P 92, R 18, SaO2 98 on 2L NC. Mr. Greer has just been visited by his wife. Dysfunctional Gastrointestinal Motility False She has been documented as being obese, new onset. Mr. Wright is pleasant and cooperative, but needs to be reminded to avoid pressure on his heel and sacrum. Blood Glucose 185, 4 units of insulin sliding scale for coverage. Flexes abnormally = 3 Hopelessness False. Vital signs are to be taken BID, and it is now time. Connect telemetry Place pt on PCA pump Acute pain: False -Document and contact nursing supervisor/Charge nurse Assist physician in physical exam of patient Mr. Dominec leaves the room and you discharge him and escort him and his partner to the car. Gown and mask Deficient Knowledge False Non-significant past medical Hx. Temp 98, BP 114/67, P 115, RR 20, SaO2 98%. Evaluate outcome of dietary plan Review pain medication order Scenario 5 Impaired Mobility True The bed arrives tomorrow. Imbalanced Nutrition True Activity as tolerated with assistance. Dr. Suculo, Physiological The provider advises the Nurse to draw a stat CBC, give a liter bolus of NS, and repeat CBC. 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. Scenario 2 Assist patient Attempt to orient to person, place, and time Educate patient Scenario 1 -Check patency of Foley catheter, urine color, and ensure it is secure to the patient's leg Stoma Status: Pink-Red/Moist Dusky Retracted Excessive bulging Scenario 1 Self-Care Deficit True Physiological- Vital signs- Physiological- Scenario 1 -Discuss effectiveness of sitter Electrolyte Imbalance, Risk for True 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. Senario 2 Sa fortune s lve 1 900,00 euros mensuels Love and Belonging He is aware that he may not have an erection and may need depends for bladder incontinence. Ask patient to explain to you what procedure she was expecting to have this morning. Health Change Increased acuity Document and prepare to transfer to Surgical ICU What order are you providing the information to the receiving nurse? Consult Social Service Bleeding, Risk for True Full assessment Disoriented to time and place, speech slurred. Educate about recovery from appendectomy and care to wound. -Ensure patient privacy and call for help and assist patient to bed once help arrives -Ask Mr. Burgundy to lower his tone as it can be disturbing to other patients 97.4, Resp 16 and Pulse Ox 94%. Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. Course Hero is not sponsored or endorsed by any college or university. Scenario 2 Scenario 1 You enter room and find Ms. Gestalt crying because she has just learned her medical insurance has lapsed and she is already two months behind on her car payments. Evaluation patient after consult Check input/output for possible dehydration He has a history of hypertension and is not compliant with medication. Tear, Ecchymosis, Contusions, Bruising Her pitcher has already been filled three times this shift. -Advise patient not to get up and walk on his own Give verbal report Senario 3 Cardiovascular Assessment His partner is at the bedside asking, "how much longer will he have to wait until taken to surgery?" Grieving: False. LOC Normal acuity : 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. All our products can be personalised to the highest standards to carry your message or logo. Until the recent diagnosis of cancer, the patient had only seen a physician once in the last ten years. Tap patient and ask, "Are you okay?" Determine clinical decisions based on listening to an audible client report. Educate caller regarding HIPAA -Explain that Radium-223 mimics calcium and is absorbed during new bone growth. Enter the email address you signed up with and we'll email you a reset link. Educate patient After 24 hours, Ms. Gestalt fever and chills have subsided but now states she is feeling like her cast is too tight. Educate patient Scenario 2 Mr. Dominec had his surgical procedure and is doing great. Refer call to contact health department The charge nurse tells the nurse to take Mr. Burgundy to the floor, because his room is now ready. Scenario 5 Wash and glove hands Pain Level Increased acuity No known allergies (NKA). His, Joyce Workman Room 303 Joyce Workman Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Fall, risk for: True NKDA Assessment The client vital signs are: Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%, Neuro WNL alert and cooperative. Scenario 3 Several hours later, Mr. Duncan is now complaining of nausea. 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Impaired comfort: True 2. -Remove the lunch tray and ensure pre-operative consent has been signed. Scenario 4 Use therapeutic communication/active listening Scenario 5 Fear True Your response to all of them would be: Scenario 1 Localizes pain = 5 Start secondary large bore IV line Document results/findings Lithia Monson Self-Care Deficit False Provide comfort in pre-surgical room Mr. Dominec. Mr. Dominec has a male partner and has been married for the past ten years and share their three children to the marriage. Pain Scale: 0 to 10: _______________ Swift River Reflection Questions day 7 Answer each question thoroughly in multiple sentences. Sarah Getts He does not have an IV nor is he on oxygen. Nausea: False Yes Acute Confusion: True Dr. Donofrio, Chronic Pain, Risk for constipation, impaired nutrition, anxiety, fear, grieving, hopelessness, powerlessness, Daily Flowsheet & Physical Assessment, Vital Signs Intake & Output Provide information for MD to call family at home and explain what has just happened Educate patient/family Obtain urinary screen Document results Fear True Skin Integrity: Intact No, describe below, Location Type Size Wound bed Drainage Urostomy: N/A Urostomy/Ileal conduit Acute pain: True Pain re-assessment Document results Full assessment Bleeding False He states, "This is not serious." Upon entering room, you wash/glove hands. Pupils PERRLA, eyes clear. Vital signs -Temp 98.6, BP 114/62, P 100, RR 20, SaO2 94%. Skin: Warm/dry Clammy/diaphoretic Skin Turgor: Brisk Tenting Evaluate understanding. -If gastric reflux is suspected administer PRN antacids (GI cocktail)