Fall, Risk for True Scenario 4 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. Obtain translatorT -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. Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. She has just been transported from recovery. -Discuss with sitter that patient needs continual observation Regular diet. Acute pain: False Combien gagne t il d argent ? Imbalanced Nutrition True Blood, Glucose 185, 4 units of insulin sliding scale for coverage. Mr. Richardson is now pain free and questioning why he is plagued with recurring urinary stones. Scenario 4 Do not probe further Scenario 5 Psychological Needs Normal acuity Deficient Knowledge True Evaluate learning Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. Call Rapid Response protocol initiated Wash and glove hands Remain with patient -Provide a diversional activity to pass the time while waiting on the HCP and inform wife that the HCP will be coming soon Listen to patient concerns Infection, risk for: False. Document results Incomprehensible Blood Pressure, 7a-7p Total: 7p-7a Total: -Give NS liter bolus Obtain patient record and follow patient as he is transferred to ICU He has partial thickness burns to his left arm and the left side of his face. Scenario 1 ADA diet, intake 25%. The Physician tells you to have everything ready including a 22 French chest tube, and he will be in shortly to position the chest tube. Scenario 3 Educational needs: Increased acuity , a 58-year-old male patient presents to the ER CO CP 10/10. The patient was placed on 2 L O2 NC, EKG monitoring to include a 12 lead, Pulse Oximeter. Dr. Donofrio. Educate patient ADA diet, intake, 25%. Noncompliance: False Scenario 1 Sleep Deprivation False 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. Assessment of bowel movement -Call security for assistance and compliance officer Scenario 2 Emergency intubation and assisted breathing is provided for Mr. Thomason -Check patency of Foley catheter, urine color, and ensure it is secure to the patient's leg Verify call light/bed safety precautions Mr. Mancia is holding Catholic Rosary in hand and is crying as you enter the room. Respiratory Assessment Upon entering the room, you find Ms. Rails sleeping. Apply restraint Scenario 1 Provide verbal report to team members who respond to rapid response Evaluate understanding Assess for bowel sounds Robert Domenic Pain Level: Increased acuity Scenario 5 Scenario 3 Oriented to: Person Place Time The patient has a Foley catheter in place and is reporting 8/10 incisional pain and he is asking why his throat is sore. Dr. Jones. Why is cysteine such an important amino acid for defining the tertiary structure of some proteins? Sensorium Increased acuit, Physiological Decreased Cardiac/perfusion: False 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. Grieving False Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. Ineffective breathing pattern False Upon entering the room, you find Mr. Sturgess is quiet, appears tense and rigid but states, -Explain that Radium-223 mimics calcium and is absorbed during new bone growth. Kathy Gestalt Oral Mucosa: Tongue: Teeth: As you enter the room, Mr. Duncan is refusing to eat foods from bland diet. The heartburn has become worse since he started treatment for his URI. nursing care plan for Linda Pittmon, a 74 -year old female patient who is a noncompliant diabetic, and frequently stays at the local homeless shelter. Obtain vital signs machine Deficient knowledge: True Non-significant past medical history. Robert Sturgess 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. He has a 20-year one pack history of smoking. His coughing, to clear his airway, appears ineffective. Vital signs -Temp 98.4, BP 116/76, P 96, RR 20, SaO2 99%. Assess intake and output and possible reasoning Senario 5 Notify lead nurse/doctor Psychological Needs: Increased acuity He warns the patient that if he does not comply with the treatment and preventive measures, he will need other treatments that may include. Full assessment of patient. No response = 1, Mobility: Wash and glove hands Alleviating Factors: Last pain medication: Day 2 admission, Thomas Richardson is complaining of severe pain and is now begging you for some relief; states pain scale 10/10. Hafencity Riverbus (Hamburg) - All You Need to Know BEFORE You Go NPO with small amount of ice chips only. BP 154/89, P 94 F, R 22, T 98.3F, SaO2 95% on room air. Notify doctor for Foley catheter Administer antipyretic meds Bleeding, Risk for False Purposive Communication Module 2, Chapter 1 - Summary Give Me Liberty! Psychological Needs Normal acuity Scenario 2 Scenario 5 When you enter the room, the patient is having chest pain again, and they are pale and diaphoretic. -Elevate head of bed and place the patient on Pulse oximetry. Ms. Gestalt is second day post-op and has requested to get out of bed and to ambulate to bathroom. Scenario 3 Extends abnormally = 2 Health Change Increased acuity 97.4, Resp 16 and Pulse Ox 94%. Adjust crutches Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. Students also viewed Culture Concept notebook Development concept notebook Elimination concept notebook Gas Exchange concept notebook If family/visitors come, will need education to airborne precautions. Cross), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. 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Impaired Mobility True Several hours later, Mr. Duncan is now complaining of nausea. Visual assessment Upon assessment, you determined that she is confused to person, time, and place but is easily directable. -Contact HCP to determine when they are available to speak with the patient Scenario 4 Impaired comfort: True 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. Notify lead nurse/doctor There is an order to apply a waist belt restraint if needed. Educate patient The Elbe River - hamburg.com Scenario 3 Use therapeutic communication/Active Listening -Ensure patient privacy and call for help and assist patient to bed once help arrives "I am feeling fine." The tour started nicely through the new area Hafencity but then continued to the area under development and a very desolate district of Hamburg. Diet as tolerated. They were also concerned about the next patient going into that room and the use of the lavatory. Scenario 2 Senario 3 Impaired Skin Integrity False 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. -Reorient Patient to person, place, & time The nurse identifies self to the nurse triaging patients and is directed to trauma room 4. Ms. Gestalt is now complaining of fever and chills. Failure to Thrive False. Awaiting diagnostic labs. Observe closely first hour Peripheral Neurovascular Dysfunction False Document results Don Personal Protective Equipment Assess Scenario 5 Date of insertion: _________________________ Date of dressing: _________________________________ Bleeding, Risk for True Next time we'll spend our 60 on some food and nice beers. In the interim, start an IV and start infusing Ringers Lactate. Visual assess Stay with patient for surgeon's arrival to explain intended surgical procedure Swift River Nursing Simulation - Homework Writing Services Safety Scenario 4 Wash and glove hands Communication/Speech: Clear Non-verbal Slurred Aphasia Other Dr. Donofrio, Chronic Pain, Risk for constipation, impaired nutrition, anxiety, fear, grieving, hopelessness, powerlessness, Daily Flowsheet & Physical Assessment, Vital Signs Intake & Output Sleep deprivation False 3Check surgical consent for correct procedure and make sure operative site is marked. Document results and findings Mr. Gonzales H/H is 12.7/38. Mr. Duncan's wife meets you in hall asking what she could bring her husband to eat from home. Verbal command = 3 Evaluate/Modify Mobility Plan, Carlos Mancia, 48yr-old, Spanish speaking migrant worker with no known past medical Hx. 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. Needs frequent reminding due to determination to do things herself without assistance. -Reassess patient's physical status prior to leaving him in the hallway is a 57 y/o who has been admitted for a radical prostatectomy. Therapeutic Communication Document results He asks to speak to a clergy member. Therapeutic communication Bleeding Risk for: False Exam January 9 Spring 2020, questions - Studocu Full assessment including both lying/standing She has arrived in pre-op and about to have surgery this morning. His original lymph node biopsy was negative. Provide Operative summary of type of procedure, IV fluid and pain status. Wash and glove hands Scenario 1 Evaluate understanding Spanish interpreter available at extension 61178. Scenario 1 Imbalanced Nutrition: True Your response to all of them would be: Scenario 1 Scenario 2 Health Change Increased acuity Impaired Comfort True Activity as tolerated with assistance. Pain: No Yes: Location: ______________________ Acute Chronic Constant Intermittent Fall, risk for: True He told the nurse that he has had some changes in his bowel habits and his stools have been very dark. Mr. Greer has just returned from surgery. Senario 3 Diet as tolerated. Esteem Upon assessment, you determined that she is confused to person, time, and place but is easily directable.
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