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Scenario 2 Deficient Knowledge False -Check patency of Foley catheter, urine color, and ensure it is secure to the patient's leg Disoriented, confused = 4 Non-significant past medical history. Eye opening Spontaneous = 4 Document and prepare to transfer to Surgical ICU Impaired Gas Exchange False View Swift River Reflection Questions (1).docx from NRSG 4412 at South College. Ms. Gestalt is now complaining of fever and chills. -Draw a repeat CBC per HCP order to determine current Hemoglobin status Scenario 3 Apical pulse rhythm: Regular Irregular Location: PT to educate patient His VS are BP 122/64, P 89, R 12, SpO2 93%. Include patient condition change in shift report 20ga. IV Assessment/ N/A Attempt to orient to person, place, and time -Transport Mr. Burgundy to his room "I am feeling fine." Upon entering the room, you find Mr. Sturgess is quiet, appears tense and rigid but states, Scenario 2 Ineffective Peripheral Tissue Perfusion False Taking HIV Meds prophylaxis. Senario 1 Assist patient out of bed Urinary Catheter: N/A Indwelling Short-term Indwelling Long-term Date of Insertion:________ Size: _____F Blood Glucose 185, 4 units of insulin sliding scale for coverage. Cardiovascular has pacer with rate of 82bpm on demand. RLQ: RUQ: LUQ: LLQ: Yes Productive Non-productive Describe Sputum: _______________________ Assess He has partial thickness burns to his left arm and the left side of his face. Evaluate understanding Scenario 2 Notify lead nurse/doctor Ms. Cumble states that she has not had a BM for three days. Scenario 5 Strict I&O, regular diet, intake 50%. Scenario 1 Grieving False Scenario 1 Scenario 2 Encourage fluids/fiber/ambulation Acute pain: True Cardiovascular has pacer with rate of 82bpm on demand. Encourage fluids Safety Place call light and check bed for safety You observe Ms. Getts being assisted by another nurse who is being blatantly rude and disrespectful to her. Readiness for Self-Care Enhancement True Release restraints/full range of motion Report to charge nurse/ head nurse the need for staff education. Wash and glove hands IV maintenance fluids with D5 1/2 NS with 20 KCL @ 125ml/hr in left forearm. Skin warm dry, bruises on forehead with small laceration. He was initially sedated with versed 2mg, and Fentanyl 100 mg by the EGD nurse, but the patient was not tolerating the procedure, so anesthesia was called to administer propofol. Impaired Gas Exchange True Scenario #3. Acute Pain True He requests no visitors at this time, but later asks for his family to be called to discuss a plan of care. Wash and glove hands Senario 5 Sit at an eye level. Fall, risk for: True Educational Needs Increased acuity Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. Regardez le Salaire Mensuel de Tthuchicago Org en temps rel. Neuro WNL alert and cooperative. Obtain translatorT Scenario 4 Mr. Richardson is requesting assistance to ambulate to bathroom. Noncompliance False Love and belonging Scenario 3 Notify family Urostomy: N/A Urostomy/Ileal conduit Pain Level Normal acuity Where is my camera man!! RLE: ______________ LLE: ______________, Casts/Splits: ____________________________, Motor response Verbal command = 6 -Start IV You also notice the patient is more difficult to orient. Provide for physical and thermal comfort. Pulses: Strength & Symmetry Edema: Visual assess -Administer the medication with a small sip of water and place an NPO sign at the entrance of the patient's room. Educate patient regarding patient care It is determined that Mr. Sturgess could achieve better pain control with a PCA pump. Swift River Reflection Questions day 7 Answer each question thoroughly in multiple sentences. Patient and family upset regarding dx. Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. Impaired Mobility False Ronald Burgundy Scenario 2 Patients vital signs are BP: 100/58, P: 106, R: 28, PaO2: 92%, T: 97.1 F, 36.2 C. Suprapubic Insertion site: WNL S/S Infection : ____________________ -Use therapeutic communication/active listening Scenario 4 Neuro WNL alert and cooperative. Radiofrequency ablation, which uses heat to remove abnormal esophagus tissue. Therapeutic communicationT Give verbal report Educational needs: Increased acuity Mr. Sturgess is now declining, and family members are requesting to remain in room past normal visiting hours. This information is HIPAA protected and you cannot share anything with them. Genitourinary Assessment -Reorient Patient to person, place, & time The patient got dizzy when he stood up from the commode. Senario 5 Deficient Fluid Volume False Scenario 2 Decreased cardio tissue perfusion: False Scenario 5 Inform patient about the progression and risk a PCP infection has for a patient with AIDS. Vital signs -BP 124/82, Temp 98.2, P 84, RR 22, SaO2 96%. -Discuss with sitter that patient needs continual observation Vital signs- Scenario 3 He has been taking his HIV medication daily. The nurse performs tilt test, Patient vital signs lying flat, BP 118/62, P 92, R 20, T 98.5, SpO2 97. Skin integrity, impaired True Listen to patient concerns 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. Ineffective Airway Clearance True No Known allergies (NKA). Senario 2 Ineffective airway clearance True BP 154/89, P 94 F, R 22, T 98.3F, SaO2 95% on room air. Three hours later, Ms. Getts is unsteady when standing by her bedside. After 24 hours, Ms. Gestalt fever and chills have subsided but now states she is feeling like her cast is too tight. What is the ratio of Fe\mathrm{Fe}Fe (II) atoms to Fe(III) atoms in this compound? Seek clarification Deficient Knowledge False Acute Pain True 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. Psychological Needs Increased acuity -Begin q15 minute neuro checks Remain with Patient, Sarah Getts, 77 yr-old, Dx- Chronic Renal Failure, admitted with hyperkalemia (5.9, Eq/L)/hyponatremia (128mEq/L). 20ga. Use therapeutic communication/Active Listening Sensorium Increased acuit, Physiological Pupils PERRLA, eyes clear. Scenario 3 Self-Actualization Offer assistance in providing more information about treatment options for newly diagnosed AIDS patients. The patient describes this pain as a heavy pressure with intermittent stabbing. r/o Tuberculosis. Acute Confusion False Notify family as to when they may come and visit. You are told that he has intermittent chest pain with substernal burning that radiates to his mid-back. Skin warm and dry, daily dressing changes, T-tube without drainage. Tunneled, site _______________ Implanted port, accessed _____________________ Scenario 5 After leaving the room the provider tells the nurse that he hopes that he scared him into compliance with the treatment options. Scenario 4 Sensorium Increased acuity, Physiological : an American History (Eric Foner), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Reassure patient of options Describe the physical changes from aging and the care required. Decisional Conflict True Scenario 2 Mrs. Stukes is feeling nauseated. Bowel sounds: Active, Hyperactive, Hypoactive, Absent (listen for full 5 minutes) Insertion site: Dry/Intact Redness Tenderness/Pain Warmth Coolness Swelling Drainage -Provide a diversional activity to pass the time while waiting on the HCP and inform wife that the HCP will be coming soon Physiological- Sleep Deprivation False. Mr. Greer has just returned from surgery. Physiological- Surrounding skin: Moist/Intact Red/Erythema Irritation Skin warm and, dry, all vital signs in WNL except 115 pulse, which is normal for him. -Attempt to orient to person, place, and time Gown and mask Document results and findings Evaluate understanding Dr. Rondeau, Educational Needs Increased acuity John Duncan, 56yr-old male, Dx- Gastroenteritis, returned yesterday from Cancun, c/o intractable diarrhea, weak, pale, and refusing to eat. No known allergies (NKA). Health Change Increased acuity Ambulates with assistance. Arthur Thomason, 56-year-old MVA victim, fourth day post op with a splenectomy and femur repair. -Ensure there is suction in the room, and check Acute Pain: True Linen Change jessdevan. -Teach the patient that there are several interventions for complications post-prostatectomy to include erectile dysfunction, post-op prostatectomies, and self-care involved with a foley catheter at home. The patient has sustained an injury to her head, that is bandaged, and is bleeding from a wound to her right arm and chest area. Senario 3 -Reassess patient The 'Strandperle' (lit. Vital signs are to be taken BID, and it is now time. Pain re-assessment He has not had his BP medication today. Evaluate learning Spanish interpreter available at extension 61178. -If gastric reflux is suspected administer PRN antacids (GI cocktail) Tap patient and ask, "Are you okay?" Dr. Starks, Physiological Assume that the oxidation state of sulfur is 2-22 and that iron atoms exist in both +2+2+2 and +3+3+3 oxidation states. Remain with patient Stools are decreasing but patient remains very weak. 1Perform full assessment and provide anti-nausea medicine. Course Hero is not sponsored or endorsed by any college or university. Educate patient Educate pt regarding changes to POC Vital sign Temp 98.4, BP 136/78, P 72, RR 20, SaO2 97%. Stat lithotripsy treatment ordered. Ineffective self-health mgmt: False, Disturbed body: False Strict I&O, regular diet, intake 50%. Notify doctor of change in condition in particular: unproductive cough and low-grade fever. There is an order to apply a waist belt restraint if needed. Obtain Clinical Hours 24/7/365 In-Class and Lab Learning Resource Improve Clinical Practice Fall, Risk for True Hx of dementia, from nursing home, fall one day ago. Grieving False Scenario 4 Peripheral Neurovascular Dysfunction False Provide comfort and pain measures Fall, Risk for True Paul Greer Iron forms a sulfide with the approximate formula Fe7S8\mathrm{Fe}_7 \mathrm{~S}_8Fe7S8. Document and provide copy for Mr. Dominec to share with his follow up appointment tomorrow. Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Scenario 5 It is now two weeks later; Mrs. Smith has returned. Assess vital results 1. Skin cool to touch and appears pale. Hopelessness: True You take his vital signs which are: Temp 101.3, Pulse 88, Resp 24, B/P 116/84. -Complete secondary assessment once the patient is in bed focusing on complaint of pain resulting from the fall Scenario #2. Scenario 2 Educate caller regarding HIPAA He insists that he is not hungry and refuses assistance with his meal. Regardez le Salaire Mensuel de Ticketmaster Beyonce Koln en temps rel. Scenario 4 Disturbed Body Image True Scenario 3 ADA diet, intake, 25%. Establish second IV Richard Dominec, A 47-year-old married father of three children has been admitted for an emergent appendectomy in the evening as soon as there is space available in the OR. Vital signs -Temp 98.4,BP 178/105, P 112, RR 28, SaO2 94%; Neuro- WNL's. Expresses fatigue, fear, concern, and desire for recovery. Evaluate outcome of dietary plan If patient statement differs from the surgical consent she has signed, notify surgeon immediately Fall Risk Increased acuity Love and belonging- Obtain translator Educate patient Scenario 5 Acute Confusion: True Health Change Increased acuity Perform pain reassessment : 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. Disturbed Sensory Perception True Outline an experimental approach to demonstrate the average RNA chain growth rate during transcription of a cloned gene in vitro. Toggle navigation Swift River. Pain, Acute True Failure to Thrive True. Imbalanced Fluid Volume, Risk for True Neuro WNL, alert, and cooperative. Nausea/Vomiting: Yes No DSD (dry sterile dressing), forehead laceration clean and dry intact. Pain Level Increased acuity Scenario 1 IV D5 1/2 NS with 20 KCL @ 125 ml/hr in left forearm. Regardez le Salaire Mensuel de Nba 2k23 Pc Review en temps rel. When she moves him to the hallway, Mr. Burgundy begins yelling at you "Do you know who I am, I demand a room! Psychological Needs: Increased acuity Waist belt restraint PRN; family sitter at bedside, assist with bath. Document results and findings Bleeding, Risk for True Combien gagne t il d argent ? He is married, and his wife is requesting to stay at his side. RUE: ______________ LUE: _____________ Mr. Dominec leaves the room and you discharge him and escort him and his partner to the car. -Determine when a hospital provided sitter will be necessary Mr. Sturgess is recently dx w/ metastatic cancer of colon and he and his family have chosen only Imbalanced Nutrition True Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. -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 -Tell the patient that they are being admitted to r/o any cardiac issues -Explain to patient why his throat may be sore Safety Vital Assessment Ms. Getts is being transferred as an emergency to Critical Care. The provider advises the Nurse to draw a stat CBC, give a liter bolus of NS, and repeat CBC. Scenario 5 Shock, Risk for: False Neuro- confusion to time and place, but oriented to self, speech clear, poor historian, did not recognize son today which is new for her; Neuro assessment and vital signs q1 hr. -Elevate head of bed and place the patient on Pulse oximetry. Skin warm and dry, may sit up on edge of bed today. Report current urinary output quantify per hour and color of urine Physical Mobility, Impaired True Senario 1 Validate NPO Status Educational Needs Increased acuity Spiritual Distress False. Mr. Mancia is holding Catholic Rosary in hand and is crying as you enter the room. Oriented to: Person Place Time Nathaniel Gonzalez In the interim, start an IV and start infusing Ringers Lactate. Contact dietary consult Senario 4 Leave to break room and not continue in conversation. The provider explains that it is a pre-cancerous stage in where the cell develops abnormal features. Respiratory Rate: WNL Tachypnea Bradypnea Today's incentive spirometry Tidal Volume is 1250ml, improvement over yesterday's 900ml. He also has metal fragments on his left side on his leg arm and torso. -Restart the IV and draw CBC 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. Notify doctor Document results Sa fortune s lve 2 216,00 euros mensuels You correctly diagnosed 11 out of 16 options. Pulse Students also viewed Culture Concept notebook Development concept notebook Elimination concept notebook Gas Exchange concept notebook -Give NS liter bolus Non-significant past medical Hx. Remind physician to wash his hands before examining the patient Psychological Needs Normal acuity She shares concern about patient's wife who is now coughing and having night sweats. You question her while reviewing her operative consent and determine that everything is correct. Vital assessment Safety LOC Normal acuity Odor: __________, No Safety Safety- Observe closely first hour Educational Needs Increased acuity Pain Level Increased acuity Fall, risk for True Put the patient on O2 NC and Fentanyl 25mcg IVP for pain. -Obtain chest tube tray and set-up pleurovac Tom Richardson Seek clarification Provide information for MD to call family at home and explain what has just happened Scenario 3 Fall, Risk for True Dr. Donofrio, Physiological He has a 20-year one pack history of smoking. -Explain that Docetaxel is a hormone therapy that suppresses the testosterone that your testicles produce producing similar results as surgical intervention. Ms. Gestalt capillary refilling is now 6 secs below cast site, extremity is swollen and cold to the touch. Water/Flush: Scenario 3 Reorient Patient to person, place, & time Senario 4 Scenario 3 Don Personal Protective Equipment Scenario 4 Scenario 4 Health Change Increased acuity Flexes & withdraws = 4 The MD on site makes the decision to intubate the patient and start ventilatory assistance and move the patient to Respiratory Intensive Care. He asks to speak to a clergy member. Provide comfort in pre-surgical room Mr. Dominec. Provide Operative summary of type of procedure, IV fluid and pain status. Combien gagne t il d argent ? Pain Level Normal acuity Gastrointestinal Assessment IV maintenance fluids with D5 1/4 NS @ 150 ml/hr X 3 then reduce rate to 75 ml/hr. The patient is being prepared for discharge and his IV has been removed. Palliative care. Teach Cameron. Why is cysteine such an important amino acid for defining the tertiary structure of some proteins? 3. Administer antipyretic meds 2Provide comfort in pre-surgical room Mr. Dominec. Safety Decreased Cardio Tissue Perfusion False Urination: WNL Burning Frequency Urgency -Advise patient not to get up and walk on his own Esteem The tour started nicely through the new area Hafencity but then continued to the area under development and a very desolate district of Hamburg. Airborne Isolation. Several hours later, Mr. Duncan is now complaining of nausea. Tibial: _____ + Bilateral Other: ______________ Generalized: Pedal: ______ + Bilateral Other: ____________ Sacrum: Non-pitting Pitting ___ +. -Notify HCP of neuro findings Observe closely first hour Seznam uivatel, kte vlastn, prodvaj nebo shnj film. Cryotherapy, which uses an endoscope to apply a cold liquid or gas to abnormal cells in the esophagus. Decreased Cardiac/perfusion False If family/visitors come, will need education to airborne precautions. Chronic Pain False LLE: Non-pitting Pitting ___+ Skin: Warm/dry Clammy/diaphoretic Skin Turgor: Brisk Tenting She has IV access and has received a small dose of Valium to reduce apprehension. Document conversation She receives the pre-op medication. Radial: ____ + Bilateral Other: _____________ RLE: Non-pitting Pitting ___ + -Reassess patients' vital signs, and place on q5 minutes continuous monitoring Decreased Cardiac/perfusion: False Stoma Status: Pink-Red/Moist Dusky Retracted Excessive bulging Vital re-assessment Skin Integrity: Intact No, describe below, Location Type Size Wound bed Drainage Fear True #ozerysnackingrounds I am so excited to be partnering with Ozery Family Bakery today. You are the now the Surgical ICU nurse assigned to her. Ineffective Self-Health Management False Contact Social Services Noncompliance True. Wound clean dry and intact. Constipation, Risk for True Grieving: True Offer bedpan Vital signs are: B/P 112/78, temp. Pulse Ox: ___________ % on ____________FiO2; Room Air; Delivery Device Check PRN pain order Offer nutrition and/ or toileting -Medicate for pain Peripheral Neurovascular Dysfunction True. Robert Sturgess Scenario 1 Mr. Sturgess is recently diagnosed with metastatic cancer of colon and he and his family have chosen only palliative care. Imbalanced Nutrition: True Primary: Check LOC, Orientation, Breathing, Circulation, Brief Neuro assessment to include spinal pain or deformities, Obvious injuries. Scenario 1 Fall Risk: Increased acuity Fall Risk Increased acuity Impaired Gas Exchange True Check physician orders Pain Level 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. Intermittent/Continuous Other: 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. Document results Scenario 4 Chronic Pain False 1. The lesion was identified as Kaposi's Sarcoma. Obtain and provide the infectious disease doctor's contact information for him. Employ therapeutic communication: present reality Administer pain medications Notify Doctor for pain medz Arthur Thomason Toileting, Medications List/Times of Medications/Routes of medication, Neurological Assessment Identify patient ASA is held but morphine 4 mg was given after his GI cocktail. Scenario 1 Grieving: False. Self-Care Deficit False Ronald Burgundy Full assessment Enter the email address you signed up with and we'll email you a reset link. Scenario 1 Allergic to sulfa drugs. Construct dietary consult (plan) Last pain medicine 2hrs ago at 1300(Demerol 50mg/ Zofran 4mg IV). They would also like to start Radium-223. Evaluate understanding Upon assessment, you determined that she is confused to person, time, and place but is easily directable.