Knowledge Deficit True Upon entering the room, the patient appears to be trying to get out of bed Blood Glucose 185, 4 units of insulin sliding scale for coverage. BP 154/89, P 94 F, R 22, T 98.3F, SaO2 95% on room air. Senario 5 Amount:________ Scenario 4 Education of Foley Cath Procedure Fall, risk for: True Viola Cumble Offer assistance in providing more information about treatment options for newly diagnosed AIDS patients. Document findings/results, Ann Rails, 38 years old, c/o back pain, non-significant past medical history. Document pt's statements. Therapeutic communication Document results Mrs. Stukes is a failed laparoscopic cholecystectomy that resulted in a bowel resection with a temporary ileostomy in place. Senario 4 He also complains that his throat is still very sore. Senario 4 -Provide the patient with the time when HCP will come discuss options with him Scenario 2 0800 1200 Notify doctor Scenario 4 Filmotka filmu Najvyia ponuka (2013). Scenario 2 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 Obtain recent chest X-ray reports and recent ABG's for physician to review Scenario 2 -Explain to patient why his throat may be sore Impaired Comfort True What order are you providing the information to the receiving nurse? Lithia Monson Mr. Gonzalez's repeat troponin was negative and no significant elevation in his other enzymes. Senario 3 Patient, and family upset regarding dx. PT to educate patient Impaired Skin Integrity, Risk for True Senario 3 Anxiety True Upon entering room, you wash/glove hands. Disturbed Body True Shock False Health Change Increased acuity -Reassess patient's physical status prior to leaving him in the hallway Don Personal Protective Equipment She has IV access and has received a small dose of Valium to reduce apprehension. Wash and glove hands -Notify HCP of neuro findings Mr. Greer has just been visited by his wife. Blood Pressure, 7a-7p Total: 7p-7a Total: Impaired Skin Integrity, False Scenario 5 Explain reason for assessment and procedure Purposive Communication Module 2, Chapter 1 - Summary Give Me Liberty! Acute Pain True Upon assessment, you determined that she is confused to person, time, and place but is easily directable. Wash and glove hands Scenario 3 Mr. Sturgess does not have a living will or durable power of care completed. Senario 4 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. The sister of Mr. Mancia calls from home to speak with you. Fall Risk Increased acuity Educational Needs Increased acuity Scenario 4 Mr. Greer is on the floor still but is awake and oriented and is complaining of back pain below his right scapula. -Ensure patients is positioned in bed properly Constipation False 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. -Transport Mr. Burgundy to his room The patient states that the symptoms occurred in the middle of the night and woke him from his sleep. Sensorium Increased acuity, Physiological Educate patient -Check patency of Foley catheter, urine color, and ensure it is secure to the patient's leg Scenario 1 Health Change Increased acuity Remain with patient and reassure Genitourinary Assessment Social Isolation, Risk for True Re-assess patient He insists that he is not hungry and refuses assistance with his meal. Bowel Movement Total: x________________, Hygiene Times Description: Sharp Stabbing Throbbing Aching Cramping Other: Scenario 3 Sleep deprivation: False Wash and glove hands Evaluate patient learning Use therapeutic communication/Active Listening Vital Assessment Decreased Cardio Tissue Perfusion False Connect telemetry Skin warm and dry, may sit up on edge of bed today. Assess Scenario 4 He is excited and tells the nurse he is starving and glad that he finally gets to eat. Ms. Gestalt is now complaining of fever and chills. All opinions are mine alone. Skin warm and dry, all vital signs in WNL Validate NPO Status Offer nutrition/toilet Upon entering room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." . ADA diet, intake, 25%. An abc-phase-sequence three-phase balanced wye-connected source supplies power to a balanced wye-connected load. Document results and findings Assessment of bowel movement Obtain translator -Reassess patient q 5 minutes until awake, then 15 minutes until they are fully awake (not Drowsy). Scenario 3 Hopelessness: True Blood Glucose 185, 4 units of insulin sliding scale for coverage. No known allergies (NKA). The emergency bathroom light goes off and the nurse finds Mr. Greer on the floor in the bathroom. Pain: No Yes: Location: ______________________ Acute Chronic Constant Intermittent Allow family to remain Comfort/Pain Assessment Decisional Conflict False Ineffective Peripheral Tissue Perfusion False Educate patient Encourage to ambulate with assistance to void if needed Observe closely first hour The pain makes him short of breath. Notify doctor Tom Richardson, 46yr-old. She has received a dose of Hydrocodone for PRN pain 20 minutes ago. Esteem Provide Operative summary of type of procedure, IV fluid and pain status. -Complete incident report. Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. Why is cysteine such an important amino acid for defining the tertiary structure of some proteins? Document results/findings -Complete neuro checks as ordered No known allergies (NKA). Abdominal Pain: Non-tender Tender/Pain Describe: Educational needs: Increased acuity He is having some difficulty hearing and complains of ringing in his ears. Anxiety False Neuro WNL alert and cooperative. Robert Sturgess - Swift River Swift River University Nightingale College Course Concepts of Nursing I (BSN 246) Academic year2022/2023 Helpful? Scenario 4 Sitting, BP 109/60, P 114, Standing the patient becomes very lightheaded and the nurse has them lay back down. ASA is held but morphine 4 mg was given after his GI cocktail. Document and prepare to transfer to Surgical ICU 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. Decreased Cardiac/perfusion: False Remind staff that Universal Precautions are practiced at this hospital for all patients regardless of known infectious diseases. Pain Level Increased acuity -Discuss effectiveness of sitter Knowledge Deficit True Imbalanced Nutrition True Notify family as to when they may come and visit. To access your Swift River Virtual Clinicals login to ATI's Student Portal and access the Virtual Clinical card in My ATI. Senario 5 20ga. Evaluate/Modify Mobility Plan, Carlos Mancia, 48yr-old, Spanish speaking migrant worker with no known past medical Hx. It is determined that Mr. Sturgess could achieve better pain control w/ a PCA pump Shock, Risk for: False Deficient Knowledge True Senario 2 Gait: ______________________________, Skin Integrity Assessment Escort patient to vehicle Scenario 2 Cardiovascular has pacer with rate of 82bpm on demand. Imbalanced Nutrition: True Check input/output for possible dehydration -Tell the patient that they are being admitted to r/o any cardiac issues -Advise sitter to notify nurse when leaving the room -Complete full assessment, to include neuro Acute Pain False Encourage fluids/fiber/ambulation Mr. Mancia's vital signs upon assessment are Temp 101.2, P 94, RR 20, BP 122/82, SaO2-91%. Obtain and provide the infectious disease doctor's contact information for him. Scenario 3 I need to be reporting!" Neuro WNL alert and cooperative. 1. -Discuss with sitter that patient needs continual observation Vital sign Temp 98.4, BP 136/78, P 72, RR 20, SaO2 97%. No Known allergies (NKA). -Inform Mr. Burgundy that he cannot report from the ED, as patient privacy is strictly protected by HIPPA No Known allergies (NKA). Fall, risk for: True SANE nurse to make second visit today. Present health assessment including B/P and LOC and dressing. Decreased Cardiac/perfusion False Ms. Gestalt is second day post-op and has requested to get out of bed and to ambulate to bathroom. Ineffective Peripheral Tissue Perfusion False Tom Richardson Fall, Risk for False Clinical 2. -Notify charge nurse Scenario 5 Three hours later, Ms. Getts is unsteady when standing by her bedside. Chronic Pain False Full assessment Scenario 5 Pain Level Increased acuity Administer antipyretic meds Two housekeepers, who were refusing to clean the room, are in the break room. -Explain to Mr. Greer that it may take several days for healing, and he may have temporary incontinence, but it will resolve over time. Encourage fluids and fiber diet Patient and family upset regarding dx. The heartburn has become worse since he started treatment for his URI. Observe closely first hour Strict I&O, regular diet, intake 50%. Elevate head of bed A new graduate nurse receives a call from the hospital telling them to report to the ER immediately for a disaster. The surgeon has suggested Androgen-deprivation therapy (ADT) with surgical castration (orchiectomy). Scenario 3 Impaired Mobility True Impaired Gas Exchange True You are about to call the Surgical ICU and give report. Chronic Pain False Scenario 4 Strict I&O and strain all urine, filters in bathroom. Pulse Ox: ___________ % on ____________FiO2; Room Air; Delivery Device Take vital signs before leaving the hospital again. -Start an IV Inform and educate spouse of dietary orders Elevate Extremity He is emotionally distraught, and is insisting that he be allowed to report what is going on from the ED. You take his vital signs which are: Temp 101.3, Pulse 88, Resp 24, B/P 116/84. Explain to physician what interventions you have recently initiated Encourage Mr. Dominec to discuss with his partner his best treatment options. Scenario 5 Psychological Needs Normal acuity Mr. Duncan is now complaining of feeling "dizzy" when he stands. Use therapeutic communication/Active Listening She has been documented as being obese, new onset. Physical Mobility, Impaired True Document results and findings 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. 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. Safety Explain to her family and provide contact information. Therapeutic communication. Verify call light/bed safety precautions Mrs. Pittmon states she has had numbness for years but "now I can't . Impaired Skin Integrity, Risk for False -Inform patient to not get out of bed without assistance and place call light in reach Document results. -Contact HCP to determine when they are available to speak with the patient : an American History (Eric Foner), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Bladder distention Pelvic pain Low back/flank pain Self-Actualization Skin warm and dry, daily dressing changes, T-tube without drainage. Consult Social Service Abnormal left leg weakness, gait unsteady, 5/10 on numeric pain scale. Yes However, these abnormal cells do not have the capability to spread to other parts of the body. -Explain to Mr. Burgundy that space in the ED is allocated based off of patient need Bleeding, Risk for True They would also like to start Radium-223. Primary: Check LOC, Orientation, Breathing, Circulation, Brief Neuro assessment to include spinal pain or deformities, Obvious injuries. Love and belonging Health Change Increased acuity Lung sounds are worse. Discharge instructions Apply fall risk bracelet -Place patient on 100% O2 Scenario 2 : beach pearl), in walking distance of the velgnne ferry stop, is considered the mother of all urban beach clubs. Noncompliance True -Tell the wife that you will speak to the husband, and this is apprehension is expected with this surgery/diagnosis. Stoma: N/A Colostomy Ileostomy Effluent Consistency: Pain = 2 Perform pain re-assessment Verify call Light/bed safety precautions -If gastric reflux is suspected administer PRN antacids (GI cocktail) Vital re-assessment Disturbed Body Image True Verbal command = 3 Deficient Fluid Volume True river part Answers to the questions; Fillable SOC 1 DLA 1; Fillable SOC 1 DLA 2 - Notes on Environmental effects through sociology . You arrive in room to check on her, after washing hands. Safety- Administer new pain medz Educate caller regarding HIPAA She shares concern about patient's wife who is now coughing and having night sweats. Dr. Altace, Educational Needs Increased acuity -Begin q15 minute neuro checks Record intake and output Strict I&O, regular diet, intake 50%. RLE: ______________ LLE: _____________ Educational Needs Increased acuity Robert Domenic NG tube to low suction possibly D/C'd today after Dr. Levine rounds. Call Rapid Response protocol initiated Assess for bowel sounds
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