Urine Color: Clarity: Odor: Scenario 2 Mrs. Stukes is feeling nauseated. However, these abnormal cells do not have the capability to spread to other parts of the body. Skin cool to touch and appears pale. Administer PRN constipation medications IV NS is started, and lab work is sent. Psychological Needs Increased acuity Use therapeutic communication/Active Listening -Assess patients' pain and rule out cardiac pain. It was diagnosed by a portable X-ray and quickly splinted by the ER staff. 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. Dr. Altace, Physiological- Vital signs -Temp 98.6, BP 114/62, P 100, RR 20, SaO2 94%. Assess for fall risk IV fluids of D5 1/2 NS are infusing at 100 mL/hour to his right forearm. The patient is asking you where her son is, the last place she saw him was right before the explosion. Love and belonging Today, clubs like Hamburg City Beach Club, Lago Bay, Hamburg del Mar and StrandPauli provide a relaxed summer atmosphere with a view over the Elbe. Love and belonging Isolative, appears fearful, crying, and refusing to see her husband. Health Change: Increased acuity He states, "This is not serious." -Advise sitter to notify nurse when leaving the room Extends abnormally = 2 Decreased Cardiac/perfusion False -Tell the patient that they are being admitted to r/o any cardiac issues Anxiety True Connect telemetry Swift River Clinical Practice Chamberlain University Expert James Moore Category: Nursing Description Full Document Jose Martinez Room 301 Jose Martinez, Jose Martinez, 43- year old male experiencing chest pain while watching a state rival football game earlier in the evening. The patient asks the nurse to explain about these medications and why they are in such a hurry. Clear liquid diet. Grieving False Discription, Table 4 Cross-sectional, Longitudinal, and Sequential Developmental Designs, Engagement 1 Recognizing Research Strategies, A mental health worker with a Christian worldview.docx (Auto Recovered), NPO Breakfast: __________% Lunch ______________ %, Ethics and Social Responsibility (PHIL 1404), Care of the childrearing family (nurs420), Advanced Care of the Adult/Older Adult (N566), Business Professionals In Trai (BUSINESS 2000), Microsoft Azure Architect Technologies (AZ-303), Nurs & Healthcare I: Foundations [Lec] (NURS356), Accounting Information Systems (ACCTG 333), Bachelor of Secondary Education Major in Filipino (BSED 2000, FIL 201), Methods of Structured English Immersion for Elementary Education (ESL-440N), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), C228 Task 2 Cindy - Bentonville - Passed with no revisions, Lesson 4 Modern Evidence of Shifting Continents, MMC2604 Chapter 1 Notesm - Media and Culture: Mass Communication in a Digital Age, Lesson 17 Types of Lava and the Features They Form, Lesson 9 Seismic Waves; Locating Earthquakes, Analysis of meaning and relevance of History from the millennial point of view, Entrepreneurship Multiple Choice Questions, (Ybaez, Alcy B.) Senario 2 -Reorient Patient to person, place, & time Scenario 3 -Instruct Mr. Burgundy and his cameraman to stop immediately Place call light and check bed for safety Document results Escort patient Her pitcher has already been filled three times this shift. -Reassure patient that he will be moved to a private room as soon as possible 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. Mr. Greer has just been visited by his wife. Grieving False He replies, "six times in the past four hours". Several hours later, Mr. Duncan is now complaining of nausea. Yes You have them remain with you, seated in comfortable place, while you call ICU and attempt to locate physician for them. Encourage fluids Sensorium Increased acuity, Physiological Kathy Gestalt 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. Noncompliance False Sa fortune s lve 2 216,00 euros mensuels Noncompliance True. The lesion was identified as Kaposi's Sarcoma. Impaired Urinary Elimination True Love and belonging Senario 3 Scenario 2 Infection, Risk for False Chronic Confusion False Scenario 3 Safety- Observe closely first hour Perform full assessment and provide anti-nausea medicine. Need frequent reminder to stay in room and maintain mask precautions. Blood Glucose 185, 4 units of insulin sliding scale for coverage. Mr. Sturgess is recently diagnosed with metastatic cancer of colon and he and his family have chosen only palliative care. Psychological Needs: Increased acuity There is an order to apply a waist belt restraint if needed. To access your Swift River Virtual Clinicals login to ATI's Student Portal and access the Virtual Clinical card in My ATI. If patient statement differs from the surgical consent she has signed, notify surgeon immediately Disoriented, confused = 4 It is unclear if he lost consciousness. Grieving: False Scenario 2 Awaiting diagnostic labs. Eye opening Spontaneous = 4 Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Physiological -Reassess patient's physical status prior to leaving him in the hallway After leaving the room the provider tells the nurse that he hopes that he scared him into compliance with the treatment options. Mr. Gonzales H/H is 12.7/38. Emergency intubation and assisted breathing is provided for Mr. Thomason No Known allergies (NKA). 3. Document results The nurse observes an elderly lady who is crying and has not been taken care of yet. Impaired Mobility, Risk for True Stay with patient for surgeon's arrival to explain intended surgical procedure Nursing questions and answers. Start secondary large bore IV line -Explain to the patient that he has a procedure, and he cannot eat. Neuro WNL, alert, and cooperative but worried about scarring and is reluctance regarding walking on leg. 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. Sleep deprivation False Retrieve cast removal tool Scenario 4 Scenario 4 45 terms. His children are visiting, and they are very supportive. Scenario 4 All our products can be personalised to the highest standards to carry your message or logo. Mr. Sturgess is now declining, and family members are requesting to remain in room past normal visiting hours. No known allergies (NKA). Neuro WNL alert and cooperative. Neuro WNL, alert, and cooperative. Educational Needs Increased acuity D/C plan- decrease pain and restore normal gait. Health Change Increased acuity Swift River Medical-Surgical. Full assessment of patient. The charge nurse tells the nurse to take Mr. Burgundy to the floor, because his room is now ready. He has not had his BP medication today. He is currently febrile with temperature 100.8, HR 99, BP 135/96, RR 20, PaO2 96%, nauseated with no vomiting, rebound tenderness in right lower quadrant, has elevated WBC's and surgeon feels this will be uneventful even though he has just been diagnosed with AIDS this past week. Senario 2 He is having some difficulty hearing and complains of ringing in his ears. Scenario 5 Acute Pain True It is determined that Mr. Sturgess could achieve better pain control with a PCA pump. You arrive in room to find Ms. Monson talking to herself. Impaired Comfort True Imbalance nutrition: True Deficient knowledge: True Scenario 3 Wash and glove hands Remind physician to wash his hands before examining the patient Document findings Disturbed body False Capillary Refill: _________ seconds Fall Risk Increased acuity Localizes pain = 5 Fear/Anxiety True. Hopelessness: True Impaired Home Maintenance Management False Shock, Risk for False Education of Foley Cath Procedure Hx of dementia, from nursing home, fall one day ago. Scenario 4 Bleeding False He warns the patient that if he does not comply with the treatment and preventive measures, he will need other treatments that may include. -Tell the wife that you will speak to the husband, and this is apprehension is expected with this surgery/diagnosis. You explain that his condition has worsened and now he has been taken to ICU. Scenario 4 Mr. Dominec decides he does not want to see Infectious Disease doctor about his new cough. GI WNL. Senario 4 Safety Increased acuity, Physiological Notify family Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. Vital signs -Temp 98.4, BP 116/76, P 96, RR 20, SaO2 99%. Scenario #3. Until the recent diagnosis of cancer, the patient had only seen a physician once in the last ten years. Explain to physician what interventions you have recently initiated Ronald Burgundy Family at beside. Upon entering room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." Amount: _______ Neuro WNL. Dr. Donofrio. RLE: ______________ LLE: _____________ Reasses temp in 1 hour. The ER nurse reports that his cardiac enzymes were borderline, (Troponin?, CK/CKMB?) Electrolyte Imbalance False Stoma: N/A Colostomy Ileostomy Effluent Consistency: Educational Needs Increased acuity Expresses fatigue, fear, concern, and desire for recovery. Document results and findings Evaluate outcome of dietary plan Put the patient on O2 NC and Fentanyl 25mcg IVP for pain. Scenario 5 Odor: __________, *Types: Abrasion, Burn, Laceration, Puncture, Surgical, Pressure Ulcer, Vascular Ulcer, Maceration, Excoriation, Skin Constipation False Strict I&O, regular diet, intake 50%. Risk for Infection True Ineffective Self-Health Management False Scenario 5 Scenario 5 Ineffective self-health mgmt: False, Disturbed body: False Scenario 3 Scenario 3 Educate patient 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 Vital sign assessments Acute Confusion False Offer assistance Mr. Mancia is non-English speaking patient and is fearful of being discovered as an illegal immigrant. You arrive in room to find Ms. Monson talking to herself. His CP is 7/10 and his BP is 165/96, P 92, R 18, SaO2 98 on 2L NC. Obtain recent chest X-ray reports and recent ABG's for physician to review -Ensure IV is patent, Lithia Monson Roger Clinton, 57-year-old male construction worker arrives at 0600 to be prepared for a partial thyroidectomy to determine if he has cancer. Neuro WNL, except leg pain upon movement. Nausea: False Decreased Cardio Tissue Perfusion False Vital signs- Wound clean dry and intact. Ramona Stukes, 69 yr-old, third day post-op cholecystectomy.
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