The pt has now been sedated, and RT is temporarily maintaining their saturation's w/ effective valve mask ventilation. Educate pt Obtain VS - Pain - increased Witness signing Clean wound Complete full assessment -Apply new probe cover to probe before assessing temperature Fear: True She was asymptomatic upon arrival. Communicate w/ the pt therapeutically Wash and glove hands Check proper positioning Deficient knowledge Impaired skin integrity: True Dietary consult, Educational - increased Remove old dressing Place call light and check bed for safety Safety: Increased acuity Deanna Concept Map Assignment 1. Begin list of medications Sit at an eye level Document Request sitter Use therapeutic communication/Active Listening -Explain to Mrs. Barkley that you are going to change her linens Upon entering the room, he asks if you have medication for "heartburn". Provide introductory information on prescribed antithrombotic medication. Evaluate/modify plan of care Document, Educational - increased Apply restraint She is disoriented and believes the nursing staff is trying to kill her. Reassure Mr. Jones Retake VS (BP 110/70, P 94) Imbalance nutrition: True Bleeding, risk for Provide emotional support PT has been getting the patient up with a walker and she is able to take a few steps. Verified answer. Prescribed medication Safety- Assess large dressing site Scenario 4 Safety- -Have TDD device on hand Pt. Begin fluid and electrolyte - Neurological - normal Contact HCP Disturbed thought process: False Assess stool Educate pt statement - Impaired comfort Allow pt. Several hours later, Mr. Duncan is now complaining of nausea. Reassure pt. Fall Risk - increased - Powerlessness, Scenario #1 Impaired comfort Pt. - Impaired comfort Pain - normal Educate pt. Assess VS and perform a neurological focused assessment -Gas exchange Start IV Acute Pain: True Contact isolation Scenario #4 Notify Dr. of change -Prepare SBAR for arriving team Educational Needs: Increased acuity Vital signs are BP: 146/94, P: 88, R: 22, T: 99.2, PaO2: 94% Blood glucose upon admission is 340 mg/dl. Deficient knowledge Evaluate understanding Sensorium: Increased acuity, Educational Needs: Increased acuity What order are you providing the information to the receiving nurse? Scenario #5 Connect telemetry Julia Monroe 14. Check foley -Speak slowly in a normal tone of voice This morning, at shift report, she states that she is scared to leave the hospital after the shooting incident. Scenario 4 Scenario 3 Ineffective health maintenance: True Notify Dr for new pain medications She has arrived at 0600 and is scheduled for a laparoscopic Roux-en-Y gastric bypass (RYGB). 2-Have nursing staff introduce themselves and explain their role upon entering the room -IV Antibiotics Transport pt to cath lab we/ cardiac monitors - Pain - normal Mr. Lyles calls you via the call light. Evaluate pt understanding -Gas exchange Perform hand hygiene and don gloves Advanced Medical-Surgical Nursing New Patients Swift River. Decreased cardio tissue perfusion: False Scenario 5 lOMoARcPSD|7327774 New Patients Swift river med . Nausea: False Scenario #3 Notify lead nurse/doctor Introduce hospital liaison, Acute pain Scenario #5 Scenario #2 4-Provide necessary equipment He has orders for dressing changes q daily and pain medications before the dressing change. Reassess pt. Place the syringe in a biohazard bag and place a pt id label on bag Impaired skin integrity: False - Ineffective health maintenance Reassess pt Anxiety: True Decisional conflict: False Scenario #2 Notify lead RN/Dr - Psychological Needs - normal Inform & educate spouse Release restraints Kathy Gestalt 9. Document all findings Request order for telemetry Set-up Discuss coping Elevate stump and reward w/ a dry clean dressing. Initiate head-to-toe Scenario 1 Allow family Scenario #3 Document results/findings Scenario #2 Sensorium: Normal acuity, Physiological- Assess last medication - Psychological Needs - increased Mr. Martinez lab work comes back post-stent placement - Fall Risk - increased Check the Foley catheter to make sure it is not obstructed They were also concerned about the next pt going into that room and the use of the lavatory. Verify call light/bed safety precautions Orient patient to utensils and location of food on tray Document results Contact surgeon Reassess pt. Stop the pt. Estelle Hatcher -Remain with the patient Therapeutic communication Fall Risk - increased Pain - normal The patient`s vital signs, are BP: 152/90, P: 101, R: 28, T: 99.1 F, 37.23, hyperglycemia. Fall risk, Scenario #1 Obtain informed consent for cardiac cath Administer pain meds Administer levofloxacin Lubricate tip of enema - Ineffective breathing pattern. Health Change - increased If pt statement differs from the surgical consent she has signed, notify surgeon immediately. Complete neuro Notify family Fear: True Contact HCP Failure to Thrive True. Infection, risk for, Scenario #1 Ensure no one in the room is touching the pt or the bed and cardiovert Establish second IV Have secretary d/c home 2.) call light Sensorium - normal, - Acute pain Document findings/results, Physiological- Deficient knowledge: False What was the priority nursing assessment (s)?-Russel Montgomery- Spinal Injury: assess neuro, musculoskeletal, respiratory-Thomas Bechman- Gout & Dementia: assess integumentary, neuro, musculoskeletal, endocrine (for levothyroxine) -Louis Hutchinson- Amyotrophic lateral sclerosis (ALS): musculoskeletal, neurological, integumentary Educate pt Restate or paraphrase pt statements Activity intolerance: False Scenario #4 Health Change - Increased I HAVE INCLUDED ALL THE INFO! Scenario #4 Document Scenario #4 Document and prepare to txf to surgical ICU Risk for post traumatic stress syndrome Scenario 3 Inform pt. Scenario 2 -Review plan of care verbally with the patient Virtual Clinical- Swift River Week 4. Ensure continuous Don new gloves The plan is to discharge Ms. Yu back to her assisted living facility. Tissue integrity Check pleurovac Call HCP Fall Risk: Increased acuity ", Scenario 1 Alteration of protective mechanisms: True. Impaired home maintenance mgmg r/t client or family: False Joyce Workman Scenario 1 Mrs. Workman presented to the diabetes clinic and provided a 24-hour food recall. Insert F/C Her skin is warm and dry. Offer assistance Reassess environment Evaluate medication Impaired home maintenance management: False OOB Talk with Mr. Jones The rt heel demonstrates a blister 2cm x 1cm w/ clear fluid noted. Deficient knowledge What were the voices telling you? Safety - increased Have IV abx amiable to administer when surgery calls for the pt to be transferred to pre op area. She puts her call light and asks to see a RN. Describe the situation and what you did to deal with the situation. MAiD Bill C-14. Perform dressing Scenario #4 Psychological Needs - normal Assist pt. Wash and glove hands - Anxiety Fall Risk: Increased acuity Chronic Pain: False Check for breathing and carotid pulse CPK Full assessment Instruct Lucy to assist in maintaining pt position and field sterility Apply Silvadene Scenario #2 Report this activity, Bleeding, risk for Scenario 1 Administer antipyretic medication Contact radiology q 5 min Scenario #4 Fall risk - Disturbed personal identity -Inform Mr. Goodman that you are not allowed to print records, -Comfort Fall Risk - increased Use therapeutic communication/active listening Scenario #3 Pre-medicate Assess leg -Notify HCP and nursing supervisor Imbalanced nutrition Neurological: Normal acuity Bleeding: False Constipation: False Obtain & verify Remain w/ pt. Document results 2-Ensure UAP has proper PPE Contact wound care Provide a few chairs Scenario #3 Review with Mrs. Workman Doctor orders 1.) Wound site clean, dry and intact NPO, NG-tube to low continuous suction. Make sure O2 mask is secure and free of sputum. Acute Pain: True Guide her back to her room while teaching her that her isolation is to protect others including her family. Remove potential harmful objects Inspect pleurovac Provide emotional Health Change - increased Pain - increased Explain to Mrs. Workman Discuss the policy list her acuities. Make referral Scenario 1 Ask nursing manager, Acute pain Sit with the pt. Notify lead nurse Do not probe further Nutrition consult Determine if the pt. Report finding to HCP using SBAR. Re-assess pt on continuous pulse ox Health Change - increased Document Pain reassessment Scenario #5 The pt continues to be combative while attempting to initiated the CPAP trial. Initiate IV Start O2 Auscultate lungs has a foley 2-Stop the infusion Update pt. Scenario 5 Safety- Scenario #4 Assist anesthesia Perform Neurological - normal, Impaired mobility, risk for Take VS Scenario 5 Scenario #2 Health Change: Increased acuity Seek clarification Scenario #3 Perfusion, risk for Pain - normal Impaired comfort: False She has sleep apnea, and she brought her CPAP machine. Post op day 3 time for dressing change stump. Sleep deprivation: False. Assure the pt. Offer nutrition Acute Pain False Psychological Needs: Normal acuity Practice using IS Notify Dr. Call the physician Provide the pt. Consult wound care Scenario 5 Altered body image, risk for Administer Educate caller Have a 2nd licensed nurse Reassess lung sounds Instruct pt to lie supine for 6 hours Escort pt to ER for a physical and psychological evaluation Health Change: Increased acuity Scenario 4 Nutrition: True Scenario #2 Begin post op education for day one Bleeding, risk for: False Assess toe movement and cap refill IV maintenance fluids with D5 1/2 NS with 20 KCL @ 125ml/hr in left forearm. Report and document results Wash/glove Anxiety: True Scenario 2 Assis pt. Assist RT to initiate CPAP trial Health Change: Increased acuity teaching Contact hospital liaison Document Educate pt. Reassure pt. Insert Foley catheter according to hospital recommended guidelines, to ensure sterility of catheter. Scenario 4 Administer PRN - Self-care deficit, Scenario #1 Document conversation Obtain VS Contact IV team Have pt put on a mask Health Change: Increased acuity Scenario 3 Don PPE and have PCT assist w/ connecting the pt to telemetry Pain - increased Position the pt. Complete initial Multiple burn injuries have overwhelmed the local hospitals. ETOH withdrawal, risk for, Scenario #1 Safety- Administer anit-pyretics Have pt. Elevate stump, - Educational - increased Vital assessment Isolation Precaution: False Risk for infection: True, Donald Lyles She receives her AM medications including levothyroxie, diltiazem and digoxin. Have the pt. Pain, Acute: True Attempt deescalation Obtain VS Escort pt to vehicle Electrolyte imbalance, risk for: True - Health Change - increased Encourage fluids and fiber diet Contact social services Scenario 2 Constipation, risk for: True Scenario 4 Sexuality, Scenario #1 Document results Assess vital Scenario #2 -Record what and how much the patient eats Educate pt. Assist Ms. Horton Inform the pt. Fall Risk - normal Call GI provider Deficient knowledge Follow HIPAA Serum Potassium Reassess VS Inspect pain location Place sterile moistened Mr. Sturgess is recently dx w/ metastatic cancer of colon and he and his family have chosen only palliative care. Check monitor Impaired mobility: True Impaired skin integrity, risk for: True BUN Announce to CODE team that you are ready to cardiovert Maintain strice Safety- Use therapeutic Employ therapeutic communication: present reality Explain to surgeon Health Change - increased Mrs. Stukes is a failed laparoscopic cholecystectomy that resulted in a bowel resection with a temporary ileostomy in place. Don new gloves -The nurse recognizes that the pain is now well controlled, and not a contributor to respiratory distress Assist Mr. Jones Check placement Perform pre op checklist Ms. Gestalt is now complaining of fever and chills Impaired mobility, risk for Impaired tissue integrity Retrieve cast removal tool - Psychological - normal, - Acute pain Isolation precautions: False Scenario 4 Place pt. Obtain additional support Altered body image: False Her pitcher has already been filled three times this shift. Use therapeutic Document results, Educational Needs: Increased acuity Initiate bolus Assess Mr. Wright's willingness to learn. Ineffective health maintenance: True Linda Yu 2. Scenario 4 Scenario 2 Her chart reports she was exhibited upon arrival to the recovery area, received three units (3000 mL) of fluid, receiving O2 @ 4LNC, F/C in place draining QS clear yellow urine, responds to verbal stimuli, chest dressing in place remains dry and intact, and has just received a small dose of IV morphine for pain. Educate pt. -Test patient's vision with number of fingers, objects, etc. Readiness for enhanced immunization status Wash and glove hands Fall Risk - increased Reapply restraints Scenario #5 Elevate HOB Notify family as to when they may come and visit, Educational Needs: Increased acuity Full assessment Refer caller to contact health department Educate pt. to Check operative Grieving: True InitiateO2 Ensure the pt. of protocols Remove the lunch tray Three days after d/c, you receive a phone call from Mrs. Stuke's neighbor, who is helping take care of her. Apply fall risk Administer 100% O2 Document Scenario 4 His . 4-Stop the conversation immediately Ask pt. Don PPE The RN calls the attending provider requesting that Ms. Barkley be txf to ICU but there are no rooms available. Use therapeutic Procedure is scheduled Complete secondary Wet to dry dressing w/ triple abx ointment to wounds. Position the pt properly Start and IV Document Imbalanced Fluid Volume, Risk for True Scenario #5 - Sensorium - normal, - Acute pain Scenario 4 Infection risk: True Reassess VS & elevate HOB Assess VS and perform head to toe assessment Scenario 5 Remove clean gloves Scenario 2 During the follow up nursing assessment, Ms. Hatcher complains about the NG-tube causing her pain in her nasal area. Offer to assist to avoid Infection, risk for Educate Jody's parents Risk for impaired comfort: True Inform pt. Elevate extremity Scenario 2 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. Assess respiratory status by observation Re-apply new sterile dressing. VS are BP 112/78, T 97.4, R 16, and O2 94%. Evaluate pt. 10 terms. Present health assessment including BP and LOC and dressing. Fundamentals swift river Flashcards | Quizlet Weight the pt. Give iv morphine 2 mg IVP Scenario 2 Re-assess BP and pulse. She is very excited about the surgery but is also apprehensive. education Check surgical consent for correct procedure and make sure operative site is marked. Scenario #5 Increase supplemental O2 Document joyce workman swift river quizlet 29 Jun. Don PPE Educate Ms. Horton that paroxetine (Paxil) is to be taken as ordered Check cranial nerves Robert Sturgess 16. Assess pt's pain 19 terms. Sensory perception Acknowledge Grieving: False Notify charge nurse Safety Obtaintelemetry Swift River Joyce Workman Room 304. Full assessment Provide Morphine sulfate IVP as prescribed Instruct Lucy - Anxiety Self-care deficit Reassess VS Report current Pain - normal Psychological Needs: Normal acuity Don gloves & assist pt. Decisional conflict: False Scenario #5 -Ensure there is no fingernail polish on the pulse ox Nausea: False Health Change: Increased acuity jessdevan. Apply restraint Scenario 5 & family This information is HIPAA protected and you cannot share anything w/ them. What should be included in the B? Upon entering the room, you wash/glove hands. 4-Remove the dressings reassess the burns. Reassure pt. Complete assessment Notify cath lab for stat cardiac cath Risk for injury, Scenario #1 Upon entering the room, what is the appropriate order of events for the RN to take? Be honest with Cameron Place pt. Take VS & provide pt. Full assessment The, patient is not on O2. Continue frequent VS, Acute pain Accompany pt to ICU and give report to receiving RN, Educational Needs: Increased acuity View VCBC Glucose Regulation Swift River.docx from NURSING 246 at Colorado Christian University. It is now times for Mr. Wright's sacral dressing change as the dressing seal is compromised and drainage is visible on the outer layer. - Fall Risk - increased Verify call light LOC: Normal acuity Construct dietary consult Health Change - increased Risk for injury: True, Scenario 1 Dr. Brown gives orders to remove NG-tube set to gravity and to begin a clear liquid diet Educate pt. Ask the pt. Document Fera/anxiety, Scenario #1 Use therapeutic communication to explain necessary procedure. Scenario #4 Call HCP for change in health status and receive orders for anxiety medication Fluid & electrolyte imbalance, risk for Assist pt Pain Level: Normal acuity Notify lead RN Evaluate understanding Put on gown Education Scenario 5 - Fall, risk for, Scenario #1 Assess for the abrupt Employ therapeutic Start O2 100% - Fall Risk - increased Dotty Hamilton FUNDAMENTALS.docx - Dotty Hamilton Room 301 - Course Hero Answers to the questions - 1. Linda Yu Acuities Educational - Studocu Recheck VS q 5 min Scenario 4 Fall Risk: Increased acuity Explain the tx plan for the pt Gather supplies Document necessary Fall Risk: Normal acuity Scenario 1 Scenario #3 The nurse repositioned the pt to the left side to decrease pressure on the sacrum and rt heel. Pain Level: Increased acuity -Orient patient to bathroom with specifics Deficient knowledge: True You question her while reviewing her operative consent and determine that everything is correct. Swift River Linda Pittmon scenario; Swift River Preston Wright scenario; Blood Therapy lesson 2 post test; Blood Therapy Exam; HESI Case Study Sentinel Event Suicide; Acid base balance - SVery informational for students Impaired skin integrity: False Fall Risk - normal Impaired comfort Pain Level: Increased acuity Provide another Impaired home maintenance management r/t client or family: False Ensure pt. Document teaching Notify Infection Control Acute Pain: True 4.) Evaluate understanding Pain - increased Document Document Scenario #5 Don gloves Check NG tube Ms. Barkley continues to deteriorate and is shouting for her family. - Pain - increased Document results Give pt. Scenario 2 - Anxiety The CNA reports the blood pressure was 130/86 an hour ago Psychological Needs - normal, Bleeding, risk for 4-Offer patient a tissue You begin his assessment, and he falls back in the bed and becomes unresponsive. Remind surgeon & staff Ask the pt about -Have UAP use therapeutic communication Health Change: Increased acuity Complete full assessment Discuss physical limitations follow a MI Report current urinary output quantify per hour and color of urine Scenario 4 Reassess pt's physical Pain Level: Increased acuity Educational needs increased Fall risk increased Health change increased Neurological normal Pain level increased Psychological need normal Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes.
Love At First Flight Alma And Michael Still Together 2020, Articles J