Chronic Pain False Scenario 5 Impaired Skin Integrity, Risk for False Sitting, BP 109/60, P 114, Standing the patient becomes very lightheaded and the nurse has them lay back down. Also worth mentioning is the 'Alter Schwede' - a 217t . Swift River MedSurg 1.pdf - MED-SURG SCORE: 100 TIME You observe Ms. Getts being assisted by another nurse who is being blatantly rude and disrespectful to her. student name date: nur 113 assessment swift river patient: robert sturgess handoff robert sturgess, 81 years old, metastatic ca of colon, hx of diabetes. The patient has a pneumothorax that requires a chest tube placement. The patient tells the nurse that yesterday he was, "concerned about having an erection, and now they want to cut off my testicels". Inappropriate words = 3 The cycle of freezing and thawing damages the abnormal cells. Mr. Duncan is now complaining of feeling "dizzy" when he stands. Pupils PERRLA, eyes clear. Contact Social Services The nurse was told by the gastroenterology nurse that they really struggled before they called anesthesia and they may have caused an esophageal abrasion. Mr. Gonzales H/H is 12.7/38. Encourage fluids Some hair on the left side of his head has been burned off, as well. Scenario 1 Blood, Glucose 185, 4 units of insulin sliding scale for coverage. 20ga. Assess for bowel sounds Obtain recent chest X-ray reports and recent ABG's for physician to review 50% intake. -Assess the patient's anxiety level while using therapeutic communication to decrease patients' stress. Dx- urinary stones with 3 episodes/5yrs. IV maintenance fluids with D5 1/4 NS @ 150 ml/hr X 3 then reduce rate to 75 ml/hr. You return to the break room on your floor. Sensorium Increased acuit, Physiological Deficient Diversional Activity False river part Answers to the questions; Fillable SOC 1 DLA 1; Fillable SOC 1 DLA 2 - Notes on Environmental effects through sociology . Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions StuDocu University Keiser University Western Governors University Psychological Needs Increased acuity Obtain urinary screen It is now third day post-op, the order is for Ms. Cumble to stand by bedside on both legs for 5 minutes, three times a day. Check PRN pain order Dr. Donofrio. Paul Greer Abnormal left leg weakness, gait unsteady, 5/10 on numeric pain scale. RLE: ______________ LLE: _____________ Document results, Care of the Patient with a Cardiovascular or, NCLEX - Care of Patient with an Immune Disord, Quiz: Chapter 54, Care of the Patient with an, Chapter 54: Care of the Patient with an Immun, Chapter 17, Section 5; Providing First Aid fo. Senario 1 Shock, Risk for False SANE nurse to make second visit today. Acute Pain True Hafencity Riverbus (Hamburg) - All You Need to Know BEFORE You Go Acute Pain False Insertion Site: Dry/Intact Redness/Erythema Drainage Tenderness Maceration Scenario 5 Obtain translator How was this Insertion site: Dry/Intact Redness Tenderness/Pain Warmth Coolness Swelling Drainage Swift River Reflection Questions day 7 Answer each question thoroughly in multiple sentences. -Reassess patients' vital signs, and place on q5 minutes continuous monitoring Temp 98, BP 114/67, P 115, RR 20, SaO2 98%. Acute Pain True The patient was placed on 2 L O2 NC, EKG monitoring to include a 12 lead, Pulse Oximeter. Evaluate patient understanding Safety Vital assessment Disturbed Sensory Perception True Scenario 2 Neuro WNL, except leg pain upon movement. Monitor and evaluate fluid intake Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. Med Surg - Swift River_2020 | NURS 320 Med_Surg_Swift_River_Graded A Temp Nausea: False Generalized weakness, blood tinged urine and severe pain upon urination, GI- n/v. Wash and glove hands They feel that you should share with them if he was a "real AIDS" patient or not. Verify call light/ bed safety precautions No known allergies (NKA). Love and belonging Educate pt regarding changes to POC Acute Confusion False Pain: No Yes: Location: ______________________ Acute Chronic Constant Intermittent You are about to call the Surgical ICU and give report. Apical Pulse Rate: Heart Sounds: Normal S 1 S 2 S 3 The nurse observes an elderly lady who is crying and has not been taken care of yet. Scenario 1 Allow husband to come into recovery for a quick one-minute visit. You take his vital signs which are: Temp 101.3, Pulse 88, Resp 24, B/P 116/84. Scenario 4 Full assessment Scenario 4 Fortune Salaire Mensuel de Nba 2k23 Pc Review Combien gagne t il d Assess The nurse arrives and sees a tent is being erected as a triage area, and ambulances are lined up delivering trauma patients. Dr. Altace, Educational Needs Increased acuity Senario 2 The impedance per phase in the load ist 14+j1214+j 12 \Omega14+j12. Evaluate understanding Patient demonstrates urine strain procedure. NG tube to low suction possibly D/C'd today after Dr. Levine rounds. Wash and glove hands 1Perform full assessment and provide anti-nausea medicine. Educate patient Paul Greer Failure to Thrive: True. Widespread Color Change: N/A pallor cyanosis jaundice erythema Notify doctor Provide comfort and pain measures She is also investigating bone marrow transplantation. Bleeding, Risk for: True Your Swift River Virtual Clinicals account has been linked to your ATI Student account. Educate patient Release restraints/full range of motion Tubes: None Salem Sump Nasoduodenal PEG J-Tube pH: ______ Listen to patient concerns Establish second IV Scenario 3 Stat lithotripsy treatment ordered. Neuro WNL, alert, and cooperative but worried about scarring and is reluctance regarding walking on leg. Deficient Knowledge False Non-significant past medical Hx. Senario 4 Dr. Starks, Physiological Intermittent/Continuous Other: Hypothermia False The patient is being prepared for discharge and his IV has been removed. Scenario 4 Skin: Warm/dry Clammy/diaphoretic Skin Turgor: Brisk Tenting -Check patency of Foley catheter, urine color, and ensure it is secure to the patient's leg Health Change Increased acuity Scenario 5 Fall, Risk for True -Advise patient not to get up and walk on his own Sensorium Normal acuity, Physiological Senario 3 and the GI cocktail given in the ER did relieve his CP but not completely. Impaired Mobility True Ms. Gestalt is second day post-op and has requested to get out of bed and to ambulate to bathroom. Clinical 2 Flashcards | Quizlet 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! Pain affecting: N/A Sleep Activity Exercise Relationships Appetite Concentration Perform pain re-assessment Mr. Gonzalez has returned from his EGD and is still sleeping from the sedation. The patient got dizzy when he stood up from the commode. Verbal command = 3 Esteem Apical/Radial Pulse Deficit: No Yes Murmur Valve Click Scenario 3 Tunneled, site _______________ Implanted port, accessed _____________________ No known allergies (NKA). Ms. Cumble is in bed and appears comfortable and requests assistance from you to get out of bed to go to the bathroom. Scenario 1 Contact dietary consult Therapeutic communication Notify lead nurse/doctor RLQ: RUQ: LUQ: LLQ: Nutritional Intake: Adequate Inadequate BMI: Remain with Patient, Sarah Getts, 77 yr-old, Dx- Chronic Renal Failure, admitted with hyperkalemia (5.9, Eq/L)/hyponatremia (128mEq/L). Nathaniel Gonzalez He has not had his BP medication today. Observe closely first hour Compromised Family Coping: False Present health assessment including B/P and LOC and dressing. Provide verbal report to team members who respond to rapid response Senario 5 In the interim, start an IV and start infusing Ringers Lactate. Educate patient regarding changes to POC Tom Richardson -Set-up for stat portable chest x-ray Senario 3 Swift River Medical-Surgical. Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. He is excited and tells the nurse he is starving and glad that he finally gets to eat. Nausea: False Begin post op education for day one Scenario 3 Peripheral Neurovascular Dysfunction: False This shop has been compensated by Inmar Intelligence and its advertiser. -Discuss effectiveness of sitter Provide for physical and thermal comfort. Mr. Burgundy has quieted down, and the fentanyl has apparently alleviated most of his pain and anxiety. Scenario 1 Kathy Gestalt RUE: ______________ LUE: ______________ Evaluate patient learning Why is cysteine such an important amino acid for defining the tertiary structure of some proteins? Senario 5 Deficient knowledge: False The ER nurse reports that his cardiac enzymes were borderline, (Troponin?, CK/CKMB?) Scenario 5 Mr. Dominec has a male partner and has been married for the past ten years and share their three children to the marriage. Palliative care. Educate patient regarding condition Dr. Levine, Marcella Como, 38 yr-old, Sexual Trauma Victim (Rape), unknown assailant. 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His partner is at the bedside asking, "how much longer will he have to wait until taken to surgery?" Mr. Thomason appears now better oriented and MD arrives unexpectedly to examine him. Report and document results Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. **New Patients from 2020, Post- Covid-19 Update:** **Charlie Raymond , John Duncan, Carlos Mancia, kenny barrett, Tim Jones, Julia Monroe, Donald Lyles, John Wiggins, Richard Dominec, Preston Wright, Tom Richardson, Joyce Workman, Karen Cole, Jose Martinez, Mary Barkley Charlie Raymond (for older swift river patients see other pdf files loaded at the bottom of this file) Preston Wright Room . -Assess patient's ABC (airway, breathing, circulation)