Esteem Wash and glove hands IV Fluids: INT lock IV Fluids ______________@ _____________ mL/hr Date on tubing: Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Chronic Pain, Risk for constipation, impaired nutrition, anxie, 4 units on insulin sliding scale for coverage, Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), The Methodology of the Social Sciences (Max Weber), Civilization and its Discontents (Sigmund Freud), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Give Me Liberty! Gown and mask Escort patient Scenario 1 Scenario 5 Normal Sinus Rhythm on telemetry. Flexes abnormally = 3 He does not have an IV nor is he on oxygen. Scenario 2 -Tell the patient to call immediately if the chest pain gets worse or they become short of breath Safety- Scenario 1 Health Change: Increased acuity Call rapid response -Obtain chest tube tray and set-up pleurovac -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 Sa fortune s lve 2 216,00 euros mensuels She shares concern about patient's wife who is now coughing and having night sweats. Yes Mr. Richardson is requesting assistance to ambulate to bathroom. Anxiety True Impaired comfort: True How does the Med-surg simulator work? Assess for fall risk Imbalanced Nutrition True Scenario 5 ADA diet, intake, 25%. Purposive Communication Module 2, Chapter 1 - Summary Give Me Liberty! Document results and findings Incomprehensible Talk with her stating surgery is over and she did great. Last pain medicine 2hrs ago at 1300(Demerol 50mg/ Zofran 4mg IV). He has not had his BP medication today. The provider explains that it is a pre-cancerous stage in where the cell develops abnormal features. You observe Ms. Getts being assisted by another nurse who is being blatantly rude and disrespectful to her. He was recently diagnosed with stage III prostate cancer. Skin cool to touch and appears pale. Reorient Patient to person, place, & time She receives the pre-op medication. Notify doctor and charge nurse Non-significant past medical history. NKDA Assessment The client vital signs are: Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%, Neuro WNL alert and cooperative. Noncompliance True. Radiofrequency ablation may be recommended after endoscopic resection. 2. Decreased Cardio Tissue Perfusion False -Discuss and determine sitter availability -Assess for fall risk Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma. Vital signs -Temp 99.1, BP 124/62, P 77, RR 20, SaO2 91%. Swift River Medical-Surgical. Because of the fall the provider has recommended that he stay in the hospital another night. Constipation False Acquire daily weight and food intake Educational Needs Increased acuity Provide for physical and thermal comfort. Notify lead nurse/doctor IV maintenance fluids with D5 1/2 NS at 125ml per hour in left forearm. Sa fortune s lve 2 216,00 euros mensuels Place pt on PCA pump Safety Urinary Catheter: N/A Indwelling Short-term Indwelling Long-term Date of Insertion:________ Size: _____F ExplanationAnxiety/ fear True Educational Needs Increased acuity She has received a dose of Hydrocodone for PRN pain 20 minutes ago. Report current urinary output quantify per hour and color of urine palliative care. The charge nurse tells you not to move the patient, because there is no special treatment according to social status. Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. Place call light and check bed for safety Scenario 3 Tear, Ecchymosis, Contusions, Bruising Vital assessment Obtain recent chest X-ray reports and recent ABG's for physician to review 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. Call Rapid Response protocol initiated Apical/Radial Pulse Deficit: No Yes Murmur Valve Click Vital signs -Temp 98.8, BP 102/76, P 102- irregular, RR 22, SaO2 90%, cardiovascular on telemetry with Sinus irregular rhythm. Safety- But that's changing. IV NS is started, and lab work is sent. -Inform patient to not get out of bed without assistance and place call light in reach Assist patient Teach patient about safety when getting out of bed Scenario 1 Reasses temp in 1 hour. -Tell the patient that they are being admitted to r/o any cardiac issues Health Change Increased acuity Self-Care Deficit: True Notify lead nurse/doctor Scenario 3 -Recheck Tilts after the NS bolus is complete.T Regardez le Salaire Mensuel de Nba 2k23 Pc Review en temps rel. Ms. Getts is requesting water to drink. Noncompliance True -Complete full assessment, to include neuro Evaluate patient learning Impaired Comfort True Offer assistance They would also like to start Radium-223. Estimate the length of the Neptunian year given that the Earth is 1.50108km1.50 \times 10^{8} \mathrm{km}1.50108km from the Sun on the average. Sleep deprivation False is a 57 y/o who has been admitted for a radical prostatectomy. Scenario 4 Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. Sleep deprivation: False 156 terms. Her husband who is present states, "I thought it was just a lumpectomy she was having this morning." Peripheral Neurovascular Dysfunction: False After two hours, Mr. Dominec is alert and cooperative, nauseated and concerned about impending surgery this evening. Scenario 2 Sensorium Normal acuity, Physiological Lung sounds are worse. Sensorium: Normal acuity, Bleeding, risk for: False -Remove the dinner tray and make sure the diet is soft food. Scenario 5 Failure to Thrive: True. -Notify HCP of fall, complete incident report Scenario 5 -Explain that Radium-223 mimics calcium and is absorbed during new bone growth. Chronic pain: True Document findings Yes Document results. Vital signs are: B/P 112/78, temp. Apply restraint Deficient Knowledge False Scenario 2 Retrieve cast removal tool 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. Robert Domenic Educational Needs Increased acuity Neuro WNL alert and cooperative. What is the ratio of Fe\mathrm{Fe}Fe (II) atoms to Fe(III) atoms in this compound? Sit at an eye level. Remain with patient and reassure Family Health III-Pediatrics (NSG 6435) Emergency Medical Technician (EMS 1150) Applied Research In Business (MIS 781) Anatomy & Physiology I With Lab (BIOS-251) Molecular Biology (BP 723) Newest Marketing Management (D174) Professional Application in Service Learning I (LDR-461) Professional Capstone Project (PSY-495) Theology (104) You are the now the Surgical ICU nurse assigned to her. Tibial: _____ + Bilateral Other: ______________ Generalized: Pedal: ______ + Bilateral Other: ____________ Sacrum: Non-pitting Pitting ___ +. Scenario 2 Imbalance nutrition: True Senario 2 Perform circulatory evaluation The patient has a pneumothorax that requires a chest tube placement. Elevate head of bed Chronic Sorrow False Comfort/Pain Assessment Scenario 3 Observe closely first hour Dr. Donofrio, Chronic Pain, Risk for constipation, impaired nutrition, anxiety, fear, grieving, hopelessness, powerlessness, Daily Flowsheet & Physical Assessment, Vital Signs Intake & Output His coughing, to clear his airway, appears ineffective. Vital assessment Senario 1 Tom Richardson, 46yr-old. Oral Mucosa: Tongue: Teeth: Upon entering room, you wash/glove hands. Wash and glove hands Scenario 2 The pain makes him short of breath. Toggle navigation Swift River. Yes Productive Non-productive Describe Sputum: _______________________ She is with her physician. Vital signs taken by automatic B/P Cuff q 15 minutes Impaired Mobility True Report this activity immediately to the hospital privacy officer He told the nurse that he has had some changes in his bowel habits and his stools have been very dark. Family arrive one hour after event to his prior room and find Mr. Thomason's room is empty and have no idea of the events that have just occurred. Scenario 2 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. Nausea: False Offer nutrition/toilet -Discuss with family sitter if there are any other family members who can help with monitoring Lithia She has arrived in pre-op and about to have surgery this morning. You call his doctor to inform him the family has arrived. Also worth mentioning is the 'Alter Schwede' - a 217t . They were also concerned about the next patient going into that room and the use of the lavatory. Electrolyte Imbalance True Assess food consumption and intake and output Dysfunctional Gastrointestinal Motility False Combien gagne t il d argent ? Senario 1 Validate NPO Status Our Swift River Simulations are designed to help students and practicing nurses master their skills of Prioritization, Delegation, and Sequential thinkingwithout the requirement of being onsiteor even having to download software. Re-assess patient Remain with patient Dr. Altace, Physiological- Refer call to contact health department Scenario 4 Scenario 3 No Known allergies (NKA). Use therapeutic communication/active listening Senario 2 Sexuality: True. Document findings/results, Ann Rails, 38 years old, c/o back pain, non-significant past medical history. -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 Constipation False Diet as tolerated, up ad lib after gait training. Acute pain: False Combien gagne t il d argent ? 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. Deficient Fluid Volume False It is now the second day post op and he is given discharge information. Nausea False The cycle of freezing and thawing damages the abnormal cells. -Take initial vital signs (room air Pulse Ox) Scenario 3 Mr. Gonzalez has returned from his EGD and is still sleeping from the sedation. You arrive in room to find Ms. Monson talking to herself. Senario 3 Impaired Skin Integrity, Risk for True Ms. Gestalt capillary refilling is now 6 secs below cast site, extremity is swollen and cold to the touch. Infection, risk for: False. Skin warm and dry, all vital signs in WNL RUE: ______________ LUE: _____________ Fall, risk for: True He is having some difficulty hearing and complains of ringing in his ears. Remind physician to wash his hands before examining the patient Senario 5 Senario 4 No known allergies (NKA). Scenario 4 Senario 1 Peripheral Neurovascular Dysfunction False sounds= 2 Provide comfort measures Provide comfort and pain measures Scenario 2 List the nursing care order. Scenario 2 Health Change Increased acuity Safety Fatigue True Inspect cast site Regardez le Salaire Mensuel de Ticketmaster Beyonce Koln en temps rel. Contact dietary consult Notify family as to when they may come and visit. Genitalia: WNL (skin intact, no lesions) Abnormalities Describe: __________________________ -Perform neuro assess Evaluate medication effectiveness She has IV access and has received a small dose of Valium to reduce apprehension. How was this John Duncan Ruth Cummings Trustee Vice Chair Audit Chair . Peripheral Neurovascular Dysfunction False. Discuss follow up with his doctor. He is experiencing new onset of shortness of breath and has a nasal cannula with 2L of Oxygen in place. Safety If the source voltage for the a phase is Van=12080V\mathbf{V}_{a n}=120 \angle{ 80^{\circ}} \mathrm{V}Van=12080V, and the line impedance is zero, find the phase currents in the wye-connected source. Evaluate understanding Scenario 1 Scenario 1 He is pale, weak, diaphoretic, and appears anxious. Scenario 3 Respiratory Rate: WNL Tachypnea Bradypnea Non-significant past medical history. Mr. Sturgess does not have a living will or durable power of care completed. Scenario 4 Scenario 2: 1Educate about recovery from appendectomy and care to wound. Scenario 1 Notify lead nurse/doctor Nausea/Vomiting: Yes No The cells are allowed to warm up and then are frozen again. Notify charge nurse that discharge will probably not occur today. -Reinforce the risk if patient has not been NPO and ask the patient when the last time they ate. Senario 4 Senario 2 This information is HIPAA protected and you cannot share anything with them. The patient describes this pain as a heavy pressure with intermittent stabbing. Impaired Home Maintenance management r/t client or family False Contact charge nurse. Educate caller regarding HIPAA Endoscopic resection, which uses an endoscope to remove damaged cells to aid in the detection of dysplasia and cancer. Inappropriate words = 3 -If cardiac is suspected call the provider and the rapid response team. Document results Scenario 1 Mr. Greer is on the floor still but is awake and oriented and is complaining of back pain below his right scapula. Assess for bowel sounds Too bad the cruise area was a very unatractive part of the River Elbe. Neck: ______________ Skin Color: Consistent with ethnicity pinkish-tan light-tan dark-tan light-brown dark-brown Excess Fluid Volume, Risk for False Re-assess patient Ineffective airway clearance True 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. The dinner tray is waiting for the patient in his room, and the nurse notices it is a regular diet. Check physician orders However, these abnormal cells do not have the capability to spread to other parts of the body. Full assessment Psychological Needs Increased acuity Scenario 3 Scenario 1 Offer masks to visitors Isolative, appears fearful, crying, and refusing to see her husband. Mr. Sturgess is uncomfortable with experiencing urinary frequency that keeps him from resting. Consult Social Service Verify call light/ bed safety precautions 45 terms. Impaired Skin Integrity, Risk for False -Reorient Patient to person, place, & time Iron forms a sulfide with the approximate formula Fe7S8\mathrm{Fe}_7 \mathrm{~S}_8Fe7S8. 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. Urination: WNL Burning Frequency Urgency His wife tells the nurse that he seemed very distant and did not want to talk much. Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Noncompliance: False -Inform Mr. Burgundy that he cannot report from the ED, as patient privacy is strictly protected by HIPPA Fall Risk: Increased acuity Fall, Risk for True Offer nutrition and/ or toileting Love and Belonging Deficient Fluid Volume True This will treat any cancer that may have metastasized to the bone. Vital signs are to be taken BID, and it is now time. Impaired Gas Exchange False Neuro WNL, alert, and cooperative. He is complaining of pain in his left arm, and pain in his left chest when he tries to take a deep breath. Due to this, the provider would like him to stay in the hospital for observation. Mrs. Stukes is a failed laparoscopic cholecystectomy that resulted in a bowel resection with a temporary ileostomy in place. Fear/Anxiety True. Crutches at bedside adjusted for height. Powerlessness: True, Scenario 1 Color:__________ Compromised Family Coping: False The bed arrives tomorrow. Disturbed Sensory Perception True Diet as tolerated. Reassure patient of options -Have patient remain in bed, head elevated 30 degrees Mr. Sturgess is now declining, and family members are requesting to remain in room past normal visiting hours. LOC Increased acuity Acute Pain True -Check patency of Foley catheter, urine color, and ensure it is secure to the patient's leg Skin warm dry, bruises on forehead with small laceration. Senario 5 Scenario 5 Upon entering room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." . Ms. Getts is now complaining of sudden sharp, substernal chest pain, very short of breath and is profusely diaphoretic. The nest morning the gastroenterologist informs Mr. Gonzalez that his EGD confirmed a diagnosis of Barrett's esophagus with Dysplasia. Grieving False Senario 2 Respiratory Assessment Social worker with patient this morning. Chronic Confusion False He has a 20-year one pack history of smoking. Scenario 4 -Explain to the patient that he has a procedure, and he cannot eat. Scenario 5 Impaired Mobility True NG tube to low suction possibly D/C'd today after Dr. Levine rounds. Head/Face: Symmetric Asymmetric Drooping After 24 hours, Ms. Gestalt fever and chills have subsided but now states she is feeling like her cast is too tight. -Ensure IV is patent, Lithia Monson He also complains that his throat is still very sore. Fear True Scenario 3 Health Change Increased acuity Water/Flush: Impaired Mobility False Scenario 3 Scenario #2. Vital signs -Temp 98.4, BP 116/76, P 96, RR 20, SaO2 99%. Scenario 2 Viola Cumble Offer assistance in providing more information about treatment options for newly diagnosed AIDS patients. Scenario 1 IV maintenance fluids with D5 1/2 NS with 20 KCL @ 125ml/hr in left forearm. It is determined that Mr. Sturgess could achieve better pain control with a PCA pump. Ramona Stukes, 69 yr-old, third day post-op cholecystectomy. 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. Pain, Acute True Perform pain reassessment Vital signs -Temp 98.6, BP, Erma Willis, a 65-year-old woman with a history of adenocarcinoma and multiple past episodes of related secondary infections, was admitted to the medical-surgical unit this morning with a diagnosis, Reflective Journal VCBC Post work Cellular Regulation VCBC Post Work Start Assignment Due No Due Date Points 10 Submitting a file upload Please submit your post work to Canvas within 48 hours of, Typically the concept of cellular regulation Involves the study of cancer and related diagnoses. You, his prior nurse, notice the family and respond to them. Urostomy: N/A Urostomy/Ileal conduit Neuro WNL alert and cooperative. Increased fall risk. Scenario 1 Nathaniel Gonzalez Sarah Getts Explain to her family and provide contact information. Fall, Risk for True Rich Dad, Poor Dad (Robert T. Kiyosaki) The Methodology of the Social Sciences (Max Weber) Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.) . Self-Care Deficit True 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. Educate about recovery from appendectomy and care to wound. Powerlessness True. Document results Type of Line: Peripheral, location ______________ CVL, location _____________ PICC, location _______________ 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. Educate patient The charge nurse tells you she will send someone to assist you, and to get out 2mg of Versed to have ready to sedate the patient at time of procedure. -Place patient on 100% O2 Scenario 4 Palliative care. -Contact HCP to determine when they are available to speak with the patient Peripheral Neurovascular Dysfunction True. Leave to break room and not continue in conversation. Acute Pain True Elevate Extremity Safety When completing the shift change neuro check, you notice the patient's left pupil is sluggish. Safety Increased acuity, Physiological Patient and family upset regarding dx. Psychological Needs Increased acuity Fear True The patient has been scheduled for an EGD today and has an order for Omeprazole (Prilosec) and Carafate (sucralfate). Radiofrequency ablation, which uses heat to remove abnormal esophagus tissue. Hopelessness: True Safety Increased acuity, Physiological Surrounding skin: Moist/Intact Red/Erythema Irritation : 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. -Reassess patient's physical status prior to leaving him in the hallway Gait: ______________________________, Skin Integrity Assessment Acute Pain: True No known allergies (NKA). Use therapeutic communication/Active Listening Scenario 5 -Determine when a hospital provided sitter will be necessary Encourage fluids/fiber/ambulation It is unclear if he lost consciousness. Fall Risk Increased acuity #ozerysnackingrounds I am so excited to be partnering with Ozery Family Bakery today. Obtain and provide the infectious disease doctor's contact information for him. Imbalanced Fluid Volume, Risk for True -Start IV Sensorium Increased acuit, Physiological Impaired skin integrity: False, Anxiety: True Peripheral Neurovascular Dysfunction False Stat lithotripsy treatment ordered. -Draw a repeat CBC per HCP order to determine current Hemoglobin status Ineffective Peripheral Tissue Perfusion False Extends abnormally = 2 Aggravating Factors: No Known allergies (NKA). Last Bowel Movement: Date: _____________________ Constipation Diarrhea/Loose Other: Regular diet. Regardez le Salaire Mensuel de Tthuchicago Org en temps rel. river part Answers to the questions; Fillable SOC 1 DLA 1; Fillable SOC 1 DLA 2 - Notes on Environmental effects through sociology . Administer protocol antidiarrheal medication and the GI cocktail given in the ER did relieve his CP but not completely. Senario 3 Wash and glove hands Knowledge Deficit True Bleeding, Risk for True Fear: True You are now preparing for discharge, place steps in order: Senario 1 Activity as tolerated with assistance. Bowel sounds: Active, Hyperactive, Hypoactive, Absent (listen for full 5 minutes) You are told that he has intermittent chest pain with substernal burning that radiates to his mid-back. -Offer nutrition/toilet Dr. Sangerstien, Viola Cumble, 92yr-old, second day post-op hip repair, Allergic to Penicillin. 00 Comments Please sign inor registerto post comments. Encourage fluids and fiber diet -Ensure there is suction in the room, and check Use therapeutic communication/active listening No known allergies (NKA). Safety You notice she is crying and is expressing fear that she "will always have this pain and numbness" and she doesn't think she can cope. -Elevate head of bed and place the patient on Pulse oximetry. Disturbed Body True Pain Level Increased acuity Scenario 5 -Set-up for stat portable chest x-ray Scenario 1 Oriented to: Person Place Time Combien gagne t il d argent ? Pain: No Yes: Location: ______________________ Acute Chronic Constant Intermittent 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. The surgeon has just visited with Mr. Greer 2-days post op and has informed him that the lymph node biopsies have confirmed that the cancer has metastasized, and he will need further treatment. Needs frequent reminding due to determination to do things herself without assistance. Begin post op education for day one Scenario 3 Teach Cameron. Scenario 5 You return to the break room on your floor. Safety Increased acuity, Physiological Mr. Duncan's wife meets you in hall asking what she could bring her husband to eat from home. Include patient condition change in shift report Apical pulse rhythm: Regular Irregular Location: Establish second IV Decreased Cardiac/perfusion False -Explain to Mr. Burgundy that space in the ED is allocated based off of patient need Pain Level Normal acuity Ineffective breathing pattern False Mr. Duncan is now complaining of feeling "dizzy" when he stands. Therapeutic Communication Fall, risk for: False If patient statement differs from the surgical consent she has signed, notify surgeon immediately -Begin q15 minute neuro checks His partner is not with him at this time but will arrive soon to facilitate his discharge home. There is an order to apply a waist belt restraint if needed. Mr. Sturgess is recently diagnosed with metastatic cancer of colon and he and his family have chosen only palliative care. Sa fortune s lve 10 000,00 euros mensuels Contact Social Services Hopelessness False. Scenario 3 He replies, "six times in the past four hours". Wash and glove hands Some hair on the left side of his head has been burned off, as well. Disturbed Body Image True Give verbal report Scenario 5 Check monitor Scenario 2 Mrs. Smith's surgery has now ended. Ms. Rails was medicated with hydrocodone 5 mg PO two hours ago and is now complaining of pain (8/10 pain scale). Compromised Family Coping False He does not want to return to the nursing home, and does not wish to burden or live with his children.
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