1. Primary: Check LOC, Orientation, Breathing, Circulation, Brief Neuro assessment to include spinal pain or deformities, Obvious injuries. Pupils: PERRLA Size: R: mm L: _mm Unequal Sluggish Non-reactive You now arrive in the recovery unit one hour post-surgery and you are told that the surgery went well. Generalized weakness, blood tinged urine and severe pain upon urination, GI- n/v. Endoscopic resection, which uses an endoscope to remove damaged cells to aid in the detection of dysplasia and cancer. -Complete neuro checks as ordered Contact charge nurse. Document results c/o headache- medicated with Lortab 5mg PO at 0900, takes Lomotil 10ml PRN q 4 hours last dose at 0834. Your Swift River Virtual Clinicals account has been linked to your ATI Student account. Color:__________ He is complaining of pain in his left arm, and pain in his left chest when he tries to take a deep breath. Regardez le Salaire Mensuel de Ubah Kalimat Efektif Online en temps rel. Dr. Starks, Physiological Contact head nurse or supervisor in the OR to evaluate new situation Enter the email address you signed up with and we'll email you a reset link. Bleeding Risk for: False Ineffective Peripheral Tissue Perfusion False Evaluate/Modify Mobility Plan, Carlos Mancia, 48yr-old, Spanish speaking migrant worker with no known past medical Hx. Document results Chronic Pain False Impaired Mobility True Pain affecting: N/A Sleep Activity Exercise Relationships Appetite Concentration Impaired Skin Integrity False Evaluate patient learning Surrounding skin: Moist/Intact Red/Erythema Irritation Purposive Communication Module 2, Chapter 1 - Summary Give Me Liberty! Scenario 1 Stoma: N/A Colostomy Ileostomy Effluent Consistency: He has a history of hypertension and is not compliant with medication. Scenario 5 Impaired Comfort True Type of Line: Peripheral, location ______________ CVL, location _____________ PICC, location _______________ Sitting, BP 109/60, P 114, Standing the patient becomes very lightheaded and the nurse has them lay back down. Scenario 1 The charge nurse asks you to assume the patient's nursing care. Scenario 1 Deficient Fluid Volume False Odor: __________, No Disturbed body False Deficient knowledge: True Safety Vital assessment -Ensure patients is positioned in bed properly Offer assistance Next time we'll spend our 60 on some food and nice beers. Contact Social Services Neuro WNL alert and cooperative. No known allergies (NKA). Cryotherapy, which uses an endoscope to apply a cold liquid or gas to abnormal cells in the esophagus. Pupils PERRLA, eyes clear. -Explain to patient why his throat may be sore The pain makes him short of breath. Insertion Site: Dry/Intact Redness/Erythema Drainage Tenderness Maceration Deficient knowledge: False -Complete head-to-toe assessment while patient is on the floor. Visual assess He chooses to go home and see the doctor tomorrow in his office. GI WNL. -Discuss and determine sitter availability Reorient Patient to person, place, & time -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. Imbalanced Nutrition True Respiratory Rate: WNL Tachypnea Bradypnea Use therapeutic communication/active listening Document results He has been readmitted for a red spot on his sacrum of 1 cm and a 2 cm blister on his right heel. Document results/findings Sa fortune s lve 1 900,00 euros mensuels Skin warm dry, bruises on forehead with small laceration. Document results Pulse Ox: ___________ % on ____________FiO2; Room Air; Delivery Device Verify call light/bed safety precautions The dinner tray is waiting for the patient in his room, and the nurse notices it is a regular diet. The patient will be discharged today, and he will be ordering new prescriptions. Fear True Pain Level Normal acuity IV maintenance fluids with D5 1/2 NS at 125ml per hour in left forearm. Document results Wash and glove hands He has a 20-year one pack history of smoking. Discuss his understanding about the plan of care. Robert Sturgess Robert Sturgess 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. His past symptoms for three months have been that he noticed a slight hoarseness in speaking, a slight dry cough not related to a cold, and upon examination had a "pea-size lump on the center of his neck". Deficient Diversional Activity False Adjust crutches Paul Greer He was recently diagnosed with stage III prostate cancer. Pain Level Normal acuity Notify lead nurse Sleep deprivation: False Imbalanced Nutrition False Nausea/Vomiting: Yes No Grieving: True -Inform Mr. Burgundy that he cannot report from the ED, as patient privacy is strictly protected by HIPPA Taking HIV Meds prophylaxis. Scenario 5 Insert Foley catheter Senario 3 Escort patient to vehicle Scenario 3 -Give NS liter bolus He is having some difficulty hearing and complains of ringing in his ears. Therapeutic Communication -Reassess patient's physical status prior to leaving him in the hallway Family in room with patient very concerned. Explain to physician what interventions you have recently initiated He is pale, weak, diaphoretic, and appears anxious. Esteem Regardez le Salaire Mensuel de Ticketmaster Beyonce Koln en temps rel. Scenario 1 The nurse was told by the gastroenterology nurse that they really struggled before they called anesthesia and they may have caused an esophageal abrasion. Insertion site: Dry/Intact Redness Tenderness/Pain Warmth Coolness Swelling Drainage -Ensure there is a full O2 tank on the gurney, place patient on Nasal Cannula Mr. Gonzales H/H is 12.7/38. Scenario 4 -Offer nutrition and/ or toileting Scenario 4 Love and Belonging Skin Color: Consistent with ethnicity pinkish-tan light-tan dark-tan light-brown dark-brown Mr. Greer is on the floor still but is awake and oriented and is complaining of back pain below his right scapula. Activity as tolerated with assistance. Verify call Light/bed safety precautions Chronic Pain True Noncompliance True. Sensorium Normal acuity, Physiological Nathaniel Gonzalez When you enter the room, the patient is having chest pain again, and they are pale and diaphoretic. He states, "This is not serious." Acute pain: False Deficient knowledge: True -Using therapeutic communication inform Mr. Greer that there are many treatment options, and not to leave until the HCP can come and speak with him Rapid Response team arrived including anesthesia. 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 116/76, P 96, RR 20, SaO2 99%. Provide comfort measures Scenario 2 Vital sign assessments Give verbal report You determine to apply the restraint now. Educate patient SANE nurse to make second visit today. Remain with patient Crutches at bedside adjusted for height. To access your Swift River Virtual Clinicals login to ATI's Student Portal and access the Virtual Clinical card in My ATI. Contact dietary consult Deficient Knowledge True Mr. Mancia is holding Catholic Rosary in hand and is crying as you enter the room. Visual assessment Call rapid response Chronic Pain False Assess for bowel sounds Scenario 3 Hypothermia False Allow family to remain Mr. Mancia's vital signs upon assessment are Temp 101.2, P 94, RR 20, BP 122/82, SaO2-91%. LLE: Non-pitting Pitting ___+ He has partial thickness burns to his left arm and the left side of his face. Sa fortune s lve 2 216,00 euros mensuels High fall risk. The nurse identifies self to the nurse triaging patients and is directed to trauma room 4. Cardiovascular has pacer with rate of 82bpm on demand. Wash and glove hands Encourage Mr. Dominec to discuss with his partner his best treatment options. No Known allergies (NKA). Perform full assessment and provide anti-nausea medicine. -Reassess patient 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. Scenario 2 She has just been transported from recovery. At Risk, Impaired Comfort False Peripheral Neurovascular Dysfunction: False Disturbed Body True Intermittent/Continuous Other: palliative care. Vital signs -Temp 99.1, BP 124/62, P 77, RR 20, SaO2 91%. 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. Waist belt restraint PRN; family sitter at bedside, assist with bath. John Duncan, 56yr-old male, Dx- Gastroenteritis, returned yesterday from Cancun, c/o intractable diarrhea, weak, pale, and refusing to eat. Inform patient about the progression and risk a PCP infection has for a patient with AIDS. Remain with patient He has a history of well controlled GERD with over-the-counter Tagamet (Cimetidine), and Tums. Acute Confusion True View Swift River Reflection Questions (1).docx from NRSG 4412 at South College. 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. Inform and educate spouse of dietary orders Secondary: Assess vital signs, auscultate heart, lungs, and bowl sounds. Refer call to contact health department Vital assessment Mr. Sturgess does not have a living will or durable power of care completed. Shock, Risk for False Perineal Care Continent: Yes No Brief/Diaper Now, meeting the CDC definition, he has full blown AIDS but is asymptomatic at this time. Health Change Increased acuity Imbalanced Fluid Volume, Risk for True Extends abnormally = 2 Vital signs- Robert Strurgess 2021-22, Historia de la literatura (linea del tiempo), Respiratory Completed Shadow Health Tina Jones, CH 02 HW - Chapter 2 physics homework for Mastering, BI THO LUN LUT LAO NG LN TH NHT 1, Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1. Scenario 2 Acute Confusion False Notify family as to when they may come and visit. Safety He also complains that his throat is still very sore. Cough: Pain Scale: 0 to 10: _______________ Arthur Thomason, 56-year-old MVA victim, fourth day post op with a splenectomy and femur repair. Radiofrequency ablation, which uses heat to remove abnormal esophagus tissue. Deficient Knowledge False Mr. Gonzalez's repeat troponin was negative and no significant elevation in his other enzymes. Obtain recent chest X-ray reports and recent ABG's for physician to review Senario 5 Mr. Dominec has a male partner and has been married for the past ten years and share their three children to the marriage. Amount: _______ Verify call light/ bed safety precautions -Assess for fall risk Health Change Increased acuity Too bad the cruise area was a very unatractive part of the River Elbe. Obtain patient record and follow patient as he is transferred to ICU Your response to all of them would be: Scenario 1 Assess vital results 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. Microeconomics And Behavior Robert Frank 9th Edition Author: old.bubbies.com-2022-05-03T00:00:00+00:01 Subject: Microeconomics And Behavior Robert Frank 9th Edition Keywords: microeconomics, and, behavior, robert, frank, 9th, edition Created Date: 5/3/2022 7:02:15 AM Dr. Small at bedside with patient and family. Scenario 1 Peripheral Neurovascular Dysfunction False. Scenario 4 Scenario 4 Scenario 4 D/C plan- decrease pain and restore normal gait. -Remove the dinner tray and make sure the diet is soft food. Nausea False Educate patient regarding condition Report this activity immediately to the hospital privacy officer Report to charge nurse/ head nurse the need for staff education. Fall Risk Increased acuity RLE: ______________ LLE: ______________, Casts/Splits: ____________________________, Motor response Verbal command = 6 Now, third day post-op, Mrs. Stukes appears sad and depressed upon entering the room. Bleeding, Risk for False Skin warm and, dry, all vital signs in WNL except 115 pulse, which is normal for him. Patients vital signs are BP: 100/58, P: 106, R: 28, PaO2: 92%, T: 97.1 F, 36.2 C. Home; Our Focus; Our Legacy; Our Partners; Our People; Our Fellows; Our Investments 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. Self-Care Deficit False Prior to changing shift, you enter the patient's room to complete a full assessment, and Ms. Monson is now crying asking to for someone to take her home! -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. 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. Place pt on PCA pump Scenario 3 Cardiovascular has pacer with rate of 82bpm on demand. jessdevan. Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. Pain Level Increased acuity He does not want to return to the nursing home, and does not wish to burden or live with his children. Vital signs are: B/P 112/78, temp. ADA diet, intake 25%. Sensorium Normal acuity, Physiological Remain with Patient, Sarah Getts, 77 yr-old, Dx- Chronic Renal Failure, admitted with hyperkalemia (5.9, Eq/L)/hyponatremia (128mEq/L). Use therapeutic communication/Active Listening Sensorium: Normal acuity, Bleeding, risk for: False Self-Care Deficit: True Therapeutic communication. -Offer nutrition/toilet Scenario 4 Obtain and provide the infectious disease doctor's contact information for him. He warns the patient that if he does not comply with the treatment and preventive measures, he will need other treatments that may include. Bladder distention Pelvic pain Low back/flank pain Educate pt regarding changes to POC Palliative care. 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. DSD (dry sterile dressing), forehead laceration clean and dry intact. Scenario 4 Ms. Cumble states that she has not had a BM for three days. Dr. Rondeau, Educational Needs Increased acuity Scenario 3 Dr. Anderson, Educational Needs Increased acuity Full assessment Reassure patient of options Dr. Jones. Then the bus splashed into the river for a cruise. Powerlessness: True, Scenario 1 Her husband and children remain with her in the surgical holding area awaiting transport to the OR. Color:__________ Educate patient IV maintenance fluids with D5 1/4 NS @ 150 ml/hr X 3 then reduce rate to 75 ml/hr. Yes Ineffective self-health mgmt: False, Disturbed body: False -Place patient on O2 Nasal Canula Acquire daily weight and food intake Clear liquid diet. The patient was placed on 2 L O2 NC, EKG monitoring to include a 12 lead, Pulse Oximeter. NPO with small amount of ice chips only. Disoriented to time and place, speech slurred. He replies, "six times in the past four hours". -Complete secondary assessment once the patient is in bed focusing on complaint of pain resulting from the fall No Known allergies (NKA). Scenario 4 The MD on site makes the decision to intubate the patient and start ventilatory assistance and move the patient to Respiratory Intensive Care. Upon entering the room, you find Mr. Sturgess is quiet, appears tense and rigid but states, Cross), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Week #7 Assignment - Incentive Spriometer . Sleep Deprivation False Bowel Movement Total: x________________, Hygiene Times It is now two weeks later; Mrs. Smith has returned. Upon assessment, you determined that she is confused to person, time, and place but is easily directable. Document results. Scenario 1 Your notice Mr. Thomason is lying supine, appears slightly cyanotic in his lips, is exhibiting more effort to breathe, and is increasingly restless. Document results and findings Determine clinical decisions based on listening to an audible client report. Encourage fluids/fiber/ambulation When completing the shift change neuro check, you notice the patient's left pupil is sluggish. -Advise patient not to get up and walk on his own