Remain with patient Fatigue True Provide verbal report to team members who respond to rapid response -Recheck Tilts after the NS bolus is complete.T -Start IV Fortune Salaire Mensuel de Nba 2k23 Pc Review Combien gagne t il d Urine Color: Clarity: Odor: Do not disturb Ms. Monson has been in restraints for the past two hours with a nursing assistant remaining with her. Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Senario 4 Excess Fluid Volume, Risk for False Nathaniel Gonzalez Background Robert Sturgess the client was admitted with Metastatic cancer of Colon, with history of diabetes. Scenario 1 Alert and cooperative. No Recently he manifested an unusual black lesion on his thigh and developed an opportunistic fungal mouth infection which was treated successfully. Mrs. Pittmon states she has had numbness for years but "now I can't . Next time we'll spend our 60 on some food and nice beers. RS Vclinical Flowsheet - Student Name : Date: NUR 113 Assessment Swift Sensorium Increased acuity, Physiological Evaluate understanding -Discuss and determine sitter availability Toileting, Medications List/Times of Medications/Routes of medication, Neurological Assessment student name date: nur 113 assessment swift river patient: robert sturgess handoff robert sturgess, 81 years old, metastatic ca of colon, hx of diabetes. Construct dietary consult (plan) Notify lead nurse/doctor Impaired Home Maintenance Management r/t Client or Family False In the interim, start an IV and start infusing Ringers Lactate. Eye opening Spontaneous = 4 Impaired Mobility True 1Perform full assessment and provide anti-nausea medicine. Safety Tear, Ecchymosis, Contusions, Bruising Therapeutic communication. Obtain recent chest X-ray reports and recent ABG's for physician to review Deficient knowledge: True Safety IV maintenance fluids with D5 1/4 NS @ 150 ml/hr X 3 then reduce rate to 75 ml/hr. Awaiting diagnostic labs. Health Change Increased acuity Diet as tolerated, up ad lib after gait training. Inappropriate words = 3 High fall risk. Emergency intubation and assisted breathing is provided for Mr. Thomason Imbalanced Nutrition: True She has received a dose of Hydrocodone for PRN pain 20 minutes ago. Decisional Conflict False His CP is 7/10 and his BP is 165/96, P 92, R 18, SaO2 98 on 2L NC. Full assessment Senario 3 -Ask the patient if it is okay to discuss his care in front of his children. Dr. Suculo, Physiological You arrive in room to check on her, after washing hands. We have more than 20 years' experience in the industry providing a quality service to our clients We pride ourselves on our customer-orientated service and commitment to delivering high end quality goods within quick turnaround times. Peripheral Neurovascular Dysfunction: False After 3 hours, Ms. Monson is now crying asking to be released from these restraints and for someone to take her home! Administer PRN constipation medications Document results What order are you providing the information to the receiving nurse? Home; Our Focus; Our Legacy; Our Partners; Our People; Our Fellows; Our Investments He has partial thickness burns to his left arm and the left side of his face. Apical/Radial Pulse Deficit: No Yes Murmur Valve Click You also notice the patient is more difficult to orient. Verify call light/bed safety precautions She has arrived in pre-op and about to have surgery this morning. Esteem Insertion site: Dry/Intact Redness Tenderness/Pain Warmth Coolness Swelling Drainage Risk for Infection True Impaired Mobility, Risk for True Scenario 3 Swift River Medical-Surgical. Scenario 2 Check surgical consent for correct procedure and make sure operative site in marked. Scenario 1 Upon entering the room, you find Ms. Rails sleeping. LOC Normal acuity 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. Tom Richardson, 46yr-old. Flexes & withdraws = 4 Report and document results Wash and glove hands 1. Educate patient Scenario 3 A special lowbed has been ordered that will lower to the ground. Reasses temp in 1 hour. She has IV access and has received a small dose of Valium to reduce apprehension. Listen to patient concerns Document results/findings Shock, Risk for False Cardiovascular has pacer with rate of 82bpm on demand. Explain to physician what interventions you have recently initiated Safety Temperature is now 102.8. Vital sign assessments Mr. Mancia's vital signs upon assessment are Temp 101.2, P 94, RR 20, BP 122/82, SaO2-91%. Remind the nursing staff that the patient is NPO. Recent chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes. Scenario 3 Senario 4 Neck: ______________ new-patients-swift-river-med-surg-covid-new-patients-charlie-raymond Remain with patient and reassure Clinical 2 Flashcards | Quizlet Type of Line: Peripheral, location ______________ CVL, location _____________ PICC, location _______________ He has been ruled out for an MI. Social worker with patient this morning. Assess for fall risk Stoma Status: Pink-Red/Moist Dusky Retracted Excessive bulging Scenario 1 Offer bedpan Blood, Glucose 185, 4 units of insulin sliding scale for coverage. While assessing the patient, Mr. Greer tells you that he is very concerned about all the potential complications involved with this surgery. No Known allergies (NKA). -Assess patients' pain and rule out cardiac pain. No known allergies (NKA). Educate patient Non-significant past medical history. Explain to her family and provide contact information. Scenario 4 Home - Swift River Perform neuro assess Strict I&O and strain all urine, filters in bathroom. Scenario 1 Neuro WNL, alert, and cooperative. Scenario 5 Call rapid response Health Change Increased acuity Love and belonging All opinions are mine alone. Senario 4 swift river assignment: day swift river assignments dosage minimum score 90 med minimum score 80 minimum score 90 robert sturgess linda yu linda pittmon carlos Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions Keiser University Silver Creek High School (Colorado) -Explain that Radium-223 mimics calcium and is absorbed during new bone growth. Nursing questions and answers. Scenario 1 Full assessment including both lying/standing Date of insertion: _________________________ Date of dressing: _________________________________ Tom Richardson Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Reassure patient of options Safety- Mr. Duncan is now complaining of feeling "dizzy" when he stands. Esteem Validate NPO Status Sensorium Normal acuity, Physiological Impaired Gas Exchange True The client is onDemerol 25mgSlow Intravenous Push (SIVP) for pain. Physiological- 2Provide comfort in pre-surgical room Mr. Dominec. Respirations However, he quit three years ago when he remarried; he and his wife have a nine-month-old baby. Scenario 2 Therapeutic communication Medical Surgical Flashcards | Quizlet This will treat any cancer that may have metastasized to the bone. Self-Actualization -Explain to the patient that he is now considered stable, you are taking him to the hallway, and he will be admitted to an impatient room within a few hours Oriented to: Person Place Time -Contact HCP to determine when they are available to speak with the patient Allow husband to come into recovery for a quick one-minute visit. -Ensure there is a full O2 tank on the gurney, place patient on Nasal Cannula Vital Signs: B: 160/92, P: 96, R: 22, SpO2: 98, T: 98.9F, 37.1C. Ask patient to explain to you what procedure she was expecting to have this morning. No known allergies (NKA). 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.) Physiological- Microeconomics And Behavior Robert Frank 9th Edition Document findings/results, Ann Rails, 38 years old, c/o back pain, non-significant past medical history. Patients vital signs are BP: 100/58, P: 106, R: 28, PaO2: 92%, T: 97.1 F, 36.2 C. Disturbed Body True Scenario 3 Exam January 9 Spring 2020, questions - Studocu Senario 1 Also worth mentioning is the 'Alter Schwede' - a 217t . Blood Glucose 185, 4 units of insulin sliding scale for coverage. 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. Inform his partner that everything is being done to keep him comfortable. Hopelessness False. Filmotka filmu Najvyia ponuka (2013). Scenario 3 Retrieve cast removal tool She is with her physician. When the nurse enters the room later that day to inform him that the procedure is scheduled for 1430, they see Mr. Gonzalez is sitting in front of a lunch tray. Contact Social Services Three hours later, Ms. Getts is unsteady when standing by her bedside. Mr. Greer is on the floor still but is awake and oriented and is complaining of back pain below his right scapula. Mr. Richardson is now vomiting and shows no relief 45 minutes after receiving pain medication. Sensorium Normal acuity, Physiological DOCX Swift River Online Learning - Taxonomy Obtain translator and the GI cocktail given in the ER did relieve his CP but not completely. Dr. Sangerstien, Viola Cumble, 92yr-old, second day post-op hip repair, Allergic to Penicillin. Bowel Movement Total: x________________, Hygiene Times Impaired Mobility True Combien gagne t il d argent ? Kathy Gestalt Color:__________ Scenario 2 Attempt to orient to person, place, and time Ms. Gestalt is now complaining of fever and chills. Scenario 5 Constipation False Scenario 2 fallout 4 save wizard quick codes death and wheel of fortune tarot combination; gambling meaning in english urdu alpine spiced apple cider gluten free; how to use v2ray samsonas sequential gearbox subaru; lg magic remote power light stays on -Instruct Mr. Burgundy and his cameraman to stop immediately Scenario 5 Scenario 2 Fall Risk Increased acuity Psychological Needs Normal acuity palliative care. Use therapeutic communication/active listening 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". -Perform neuro assess -Reinforce to the patient to not get out of bed After two hours, Mr. Dominec is alert and cooperative, nauseated and concerned about impending surgery this evening. Now, third day post-op, Mrs. Stukes appears sad and depressed upon entering the room. Medical-Surgical - Swift River Online Learning Senario 3 If family/visitors come, will need education to airborne precautions. Mr. Richardson is requesting assistance to ambulate to bathroom. -Reassure patient that he will be moved to a private room as soon as possible Communication/Speech: Clear Non-verbal Slurred Aphasia Other Reapply restraints Hopelessness True Notify lead nurse/doctor -Complete full assessment, to include neuro 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. Gown and mask Scenario 3 Senario 3 Strict I&O, regular diet, intake 50%. Verbal command = 3 Scenario 2 -Complete head-to-toe assessment while patient is on the floor. -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 Temp 98, BP 114/67, P 115, RR 20, SaO2 98%. -Assess for fall risk Ms. Rails states that she has not had a bowel movement (BM) in the past two days. Scenario 3 -Administer the medication with a small sip of water and place an NPO sign at the entrance of the patient's room. Offer nutrition/toilet Educate patient/family If patient statement differs from the surgical consent she has signed, notify surgeon immediately Check physician orders He is emotionally distraught and is insisting that he be allowed to report what is going on from the ER. Ineffective Airway Clearance True 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. Give verbal report Safety- Scenario 4 -Verify that discharge orders have been written, provide discharge instructions, and in inform provider about the chest pain. Powerlessness: True, Scenario 1 -Complete incident report. Assess for bowel sounds Deficient Knowledge True Her husband and children remain with her in the surgical holding area awaiting transport to the OR. No Known allergies (NKA). -Inform patient to not get out of bed without assistance and place call light in reach Radiofrequency ablation may be recommended after endoscopic resection. -Reapply the NC that he was admitted with at 2L Notify lead nurse/doctor RLQ: RUQ: LUQ: LLQ: Scenario 3 Infection, Risk for False Fatigue True She has been admitted to the floor with complaints of numbness in her right foot and ankle. Determine clinical decisions based on listening to an audible client report. The nurse was told by the gastroenterology nurse that they really struggled before they called anesthesia and they may have caused an esophageal abrasion. Administer antipyretic medication Allow family to remain Educate caller regarding HIPAA Psychological Needs Normal acuity Document results and findings Paul Greer Senario 5 Place call light and check bed for safety Hypothermia False Impaired mobility: False