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Skin warm and pale. Mr. Mancia is holding Catholic Rosary in hand and is crying as you enter the room. Med Surg - Swift River_2020 | NURS 320 Med_Surg_Swift_River_Graded A Toggle navigation Swift River. Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Airborne Isolation. 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 Peripheral Neurovascular Dysfunction False Senario 3 0800 1200 Temp 98, BP 114/67, P 115, RR 20, SaO2 98%. jessdevan. Safety- SBAR assignment.docx - SBAR(situation, background, - Course Hero Peripheral Neurovascular Dysfunction False This information is HIPAA protected and you cannot share anything with them. -Explain that Docetaxel is a hormone therapy that suppresses the testosterone that your testicles produce producing similar results as surgical intervention. Assessment of bowel movement Senario 2 Shock, Risk for False Scenario 3 -Place patient on 100% O2 Impaired Mobility False Deficient knowledge: True Document results and findings 00 Comments Please sign inor registerto post comments. Powerlessness: True, Scenario 1 Scenario 5 Anxiety True Generalized weakness, blood tinged urine and severe pain upon urination, GI- n/v. It is unclear if he lost consciousness. Psychological Needs Increased acuity Fortune Salaire Mensuel de Ubah Kalimat Efektif Online Combien gagne t Scenario 4 Administer PRN constipation medications IV NS is started, and lab work is sent. Bed Bath: Assist or Total Encourage fluids and fiber diet Educate patient Safety Scenario 3 Kathy Gestalt, 33yr-old, Dx- second day post-op open right Tibia/Fibula fracture, plaster cast in place on right lower leg. Abdomen: Flat Rounded Scaphoid Distended Palpation: Soft Taut Rigid is a 57 y/o who has been admitted for a radical prostatectomy. He asks to speak to a clergy member. Neuro WNL alert and cooperative. Palliative care. Safety c/o headache- medicated with Lortab 5mg PO at 0900, takes Lomotil 10ml PRN q 4 hours last dose at 0834. Procedure is canceled for the day and rescheduled later allowing for new consent. Scenario 3 Safety The oncologist is insistent that the treatment begin immediately. Ronald Burgundy Educate patient Psychological Needs Normal acuity In the interim, start an IV and start infusing Ringers Lactate. Skin Integrity: Intact No, describe below, Location Type Size Wound bed Drainage If family/visitors come, will need education to airborne precautions. But that's changing. The dinner tray is waiting for the patient in his room, and the nurse notices it is a regular diet. Impaired Mobility True Notify lead nurse/doctor Decreased Cardiac/perfusion: False A GI cocktail was administered, and the patient stated that it decreased his pain to a 6/10. Ms. Rails states that she has not had a bowel movement (BM) in the past two days. 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. Senario 1 Chronic Pain False Scenario 4 Senario 2 Where is my camera man!! Senario 3 Alert and cooperative. Perform pain reassessment Use therapeutic communication/Active Listening Pupils PERRLA, eyes clear. Glasgow Coma Scale 0-15 Musculoskeletal 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. Imbalance nutrition: True Fortune Salaire Mensuel de Tthuchicago Org Combien gagne t il d argent Temperature is 98.3, HR is 87, RR is16, BP is 121/74, PaO2 is 98%. Impaired home maintenance mgmg r/t client or family: False Scenario 2 Assess Mr. Richardson is now vomiting and shows no relief 45 minutes after receiving pain medication. The pain makes him short of breath. Consult Social Service Compromised Family Coping: False Sleep deprivation False Mr. Greer has just returned from surgery. Pain, Acute True Scenario 2 -Reassure patient that he will be moved to a private room as soon as possible Notify lead nurse/doctor Non-significant past medical Hx. Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma. 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. Nausea: False Nausea: False Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. 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. Mr. Sturgess is now declining, and family members are requesting to remain in room past normal visiting hours. Infection, risk for: False. Scenario 5 Excess Fluid Volume, Risk for False Toileting, Medications List/Times of Medications/Routes of medication, Neurological Assessment Temperature is now 102.8. Scenario 1 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. 2. Assess food consumption and intake and output Mr. Mancia's vital signs upon assessment are Temp 101.2, P 94, RR 20, BP 122/82, SaO2-91%. No response = 1, Mobility: Auscultate peripheral pulses and ROM. Social worker with patient this morning. All opinions are mine alone. Assess toe movement and capillary refilling Therapeutic communication. Robert Sturgess 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. Acute Pain True Arthur Thomason, 56-year-old MVA victim, fourth day post op with a splenectomy and femur repair. Mr. Burgundy has quieted down, and the fentanyl has apparently alleviated most of his pain and anxiety. Upon entering room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." . They feel that you should share with them if he was a "real AIDS" patient or not. Remain with Patient, Sarah Getts, 77 yr-old, Dx- Chronic Renal Failure, admitted with hyperkalemia (5.9, Eq/L)/hyponatremia (128mEq/L). The cycle of freezing and thawing damages the abnormal cells. Scenario 4 Scenario 3 Remind the nursing staff that the patient is NPO. Ms. Gestalt is now complaining of fever and chills. He has been ruled out for an MI. Dr. Jones. He told the nurse that he has had some changes in his bowel habits and his stools have been very dark. He requests no visitors at this time, but later asks for his family to be called to discuss a plan of care. Acute Pain True Senario 4 ExplanationAnxiety/ fear True Non-significant past medical history. Nausea False Scenario 4 Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. 3Check surgical consent for correct procedure and make sure operative site is marked. Escort patient Document Results/Findings Scenario 3 The nurse was told by the gastroenterology nurse that they really struggled before they called anesthesia and they may have caused an esophageal abrasion. The patient asks the nurse to explain about these medications and why they are in such a hurry. -Perform neuro assess Emergency intubation and assisted breathing is provided for Mr. Thomason Increased fall risk. -Discuss effectiveness of sitter Scenario 2 Administer protocol antidiarrheal medication Senario 2 You observe Ms. Getts being assisted by another nurse who is being blatantly rude and disrespectful to her. Physiological- Mr. Sturgess is uncomfortable with experiencing urinary frequency that keeps him from resting. Regardez le Salaire Mensuel de New King James Bible Download For Windows 7 en temps rel. NKDA Assessment The client vital signs are: Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%, Neuro WNL alert and cooperative. -If cardiac is suspected call the provider and the rapid response team. Mr. Sturgess does not have a living will or durable power of care completed. Health Change Increased acuity Fall Risk: Increased acuity Safety Scenario #2. Evaluate understanding. Ambulates with assistance. -Explain to the patient that he has a procedure, and he cannot eat. Upon entering room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." Combien gagne t il d argent ? There is an order to apply a waist belt restraint if needed. Administer pain medications Scenario 3 Check physician orders Administer antipyretic medication Provide comfort and pain measures Fall, Risk for True Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. The patient was placed on 2 L O2 NC, EKG monitoring to include a 12 lead, Pulse Oximeter. Peripheral Neurovascular Dysfunction: False Wash and glove hands Vital signs- Fear True Scenario 2 Anterior: ___________________________________ Posterior: ____________________________________ Insert Foley catheter He tells the nurse he has called his wife and wants to be discharged now. Stoma Status: Pink-Red/Moist Dusky Retracted Excessive bulging Cough: Mr. Gonzalez has been admitted to the floor to determine that his chest pain is not related to a cardiac event. He is pale, weak, diaphoretic, and appears anxious. Grieving: False Electrolyte Imbalance False Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Put the patient on O2 NC and Fentanyl 25mcg IVP for pain. Temp Full assessment of patient. -Complete initial post-op assessment Extends abnormally = 2 Urostomy: N/A Urostomy/Ileal conduit Scenario 2 Patient, and family upset regarding dx. It is now the second day post op and he is given discharge information. Mr. Dominec has a male partner and has been married for the past ten years and share their three children to the marriage. Scenario 2 Scenario 5 Radial: ____ + Bilateral Other: _____________ RLE: Non-pitting Pitting ___ + He has a 20-year one pack history of smoking. Educate patient regarding condition -Tell the wife that you will speak to the husband, and this is apprehension is expected with this surgery/diagnosis. 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. Impaired Urinary Elimination True -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 Acute Pain: True Stat lithotripsy treatment ordered. Apical/Radial Pulse Deficit: No Yes Murmur Valve Click Impaired Skin Integrity, Risk for False Wash and glove hands He is questioning the nurse as to why he has been admitted for heartburn. Self-Care Deficit True Recent chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes. He is excited and tells the nurse he is starving and glad that he finally gets to eat. Adjust crutches Scenario 1 swift river assignment: day swift river assignments dosage minimum score 90 med minimum score 80 minimum score 90 robert sturgess linda yu linda pittmon carlos Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions Keiser University Silver Creek High School (Colorado) Impaired Gas Exchange True Mr. Gonzalez's repeat troponin was negative and no significant elevation in his other enzymes. Nathaniel Gonzalez Nausea False Impaired Skin Integrity, Risk for False You escort them with you to the ICU. Provide Operative summary of type of procedure, IV fluid and pain status. Re-assess patient View Swift River Reflection Questions (1).docx from NRSG 4412 at South College. IV maintenance fluids with D5 1/4 NS @ 150 ml/hr X 3 then reduce rate to 75 ml/hr. -Evaluate patient's understanding of teaching Verify call Light/bed safety precautions DSD (dry sterile dressing), forehead laceration clean and dry intact. Pain re-assessment Safety She is also investigating bone marrow transplantation. Describe the physical changes from aging and the care required. You discuss this cough with Mr. Dominec to determine how long he has had it. The nurse observes an elderly lady who is crying and has not been taken care of yet. VS: BP 158/90, HR 89, R 18, T 97.8 F. Scenario 2 You notify the charge nurse that you have never taken part in inserting a chest tube. Regardez le Salaire Mensuel de Nba 2k23 Pc Review en temps rel. Diet as tolerated. Hopelessness: True Ineffective Peripheral Tissue Perfusion False Safety No Known allergies (NKA). Ineffective Peripheral Tissue Perfusion False Sensorium Increased acuity, Physiological Obtain translatorT Employ therapeutic communication: present reality Encourage to ambulate with assistance to void if needed Esteem Impaired Mobility True Fear True Scenario 5 Pain Level Increased acuity Inform and educate spouse of dietary orders 45 terms. Senario 5 His original lymph node biopsy was negative. Neuro WNL alert and cooperative. Sitting, BP 109/60, P 114, Standing the patient becomes very lightheaded and the nurse has them lay back down. Obtain translator Acute Confusion True Scenario 3 Impaired Gas Exchange True You are the now the Surgical ICU nurse assigned to her. Fall, Risk for True Palliative care. -Reassess patient The charge nurse tells you not to move the patient, because there is no special treatment according to social status. 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 Chronic Confusion False Secondary: Assess vital signs, auscultate heart, lungs, and bowl sounds. Document results She is having some difficulty breathing. Educate patient regarding changes to POC Ms. Rails was medicated with hydrocodone 5 mg PO two hours ago and is now complaining of pain (8/10 pain scale).