Document and provide copy for Mr. Dominec to share with his follow up appointment tomorrow. Acute Pain True Perform circulatory evaluation The patient is awake, alert, and oriented. Recent blood gases demonstrate falling PaO2 (hypoxemia) and increasing CO2 (Hypercapnia). Scenario 2 Pain = 2 Spiritual Distress False. Students also viewed Culture Concept notebook Development concept notebook Elimination concept notebook Gas Exchange concept notebook Use therapeutic communication/Active Listening Scenario 2 Document results and findings Put the patient on O2 NC and Fentanyl 25mcg IVP for pain. 3. Odor: __________, *Types: Abrasion, Burn, Laceration, Puncture, Surgical, Pressure Ulcer, Vascular Ulcer, Maceration, Excoriation, Skin Senario 1 Present health assessment including B/P and LOC and dressing. Infection, Risk for True Senario 4 Assess for bowel sounds Wash and glove hands Scenario 1 Also worth mentioning is the 'Alter Schwede' - a 217t . Imbalanced Nutrition True He tells the nurse he has called his wife and wants to be discharged now. You determine to apply the restraint now. Seznam uivatel, kte vlastn, prodvaj nebo shnj film. The emergency bathroom light goes off and the nurse finds Mr. Greer on the floor in the bathroom. Hx of dementia, from nursing home, fall one day ago. The cancer was more advanced than they previously had thought so inguinal lymph nodes were removed. Scenario 4 Vital assessment His partner is not with him at this time but will arrive soon to facilitate his discharge home. Love and belonging- He is emotionally distraught and is insisting that he be allowed to report what is going on from the ER. Acute Confusion False Senario 3 Ineffective Renal Perfusion, Risk for True -Reinforce to the patient to not get out of bed He is pale, weak, diaphoretic, and appears anxious. Sensorium Increased acuity, Physiological Bleeding False The patient is awake alert and oriented. sounds= 2 Sa fortune s lve 10 000,00 euros mensuels Stoma status: Pink-Red/Moist Dusky Retracted Excessive bulging Her pitcher has already been filled three times this shift. -Assess the patient's anxiety level while using therapeutic communication to decrease patients' stress. Health Change Increased acuity Wash and glove hands He does not have an IV nor is he on oxygen. When completing the shift change neuro check, you notice the patient's left pupil is sluggish. Neuro WNL, except leg pain upon movement. Temp Inspect cast site 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. Notify doctor for Foley catheter Upon entering room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." . Don Personal Protective Equipment List the nursing care order. Non-significant past medical history. LOC Increased acuity Scenario 5 A special lowbed has been ordered that will lower to the ground. Pupils: PERRLA Size: R: mm L: _mm Unequal Sluggish Non-reactive No known allergies (NKA). There is an order to apply a waist belt restraint if needed. References; Access My Virtual Clinicals; Medical-Surgical. Scenario 1 Skin Color: Consistent with ethnicity pinkish-tan light-tan dark-tan light-brown dark-brown The pain makes him short of breath. Educational Needs Increased acuity Senario 4 Isolative, appears fearful, crying, and refusing to see her husband. Call rapid response Evaluate understanding The nurse identifies self to the nurse triaging patients and is directed to trauma room 4. The nurse performs tilt test, Patient vital signs lying flat, BP 118/62, P 92, R 20, T 98.5, SpO2 97. Decreased Cardiac/perfusion False Mr. Greer is on the floor still but is awake and oriented and is complaining of back pain below his right scapula. Constipation, risk for: True Reapply restraints Cardiovascular has pacer with rate of 82bpm on demand. Check monitor Document results You enter patient's room. Scenario 2 Scenario 4 While assessing the patient, Mr. Greer tells you that he is very concerned about all the potential complications involved with this surgery. Vital Assessment Impaired Home Maintenance Management r/t Client or Family False Emergency intubation and assisted breathing is provided for Mr. Thomason jessdevan. Love and belonging The lesion was identified as Kaposi's Sarcoma. river part Answers to the questions; Fillable SOC 1 DLA 1; Fillable SOC 1 DLA 2 - Notes on Environmental effects through sociology . As you enter the room, Mr. Duncan is refusing to eat foods from bland diet. You discuss this cough with Mr. Dominec to determine how long he has had it. Grieving: False Fall, Risk for True However, these abnormal cells do not have the capability to spread to other parts of the body. Compromised Family Coping False Pregnancy and labor and delivery are not typically associated with the concept of cellular regulation, Patient: Donald Lyles,52-year old male, was admitted yesterday evening for stabilization of his uncontrolled type II diabetes. Vital signs -BP 124/82, Temp 98.2, P 84, RR 22, SaO2 96%. Mr. Wright is pleasant and cooperative, but needs to be reminded to avoid pressure on his heel and sacrum. Re-assess patient Vital sign Temp 98.4, BP 136/78, P 72, RR 20, SaO2 97%. Odor: __________, No 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. Use therapeutic communication/Active Listening Impaired Gas Exchange True Therapeutic communication. Virginia Smith, 57-year-old who has elected to have a total mastectomy based on consultation with her surgeon, a total mastectomy removes all breast tissue but leaves all or most of axillary lymph nodes and chest muscles intact. The patient is being prepared for discharge and his IV has been removed. His original lymph node biopsy was negative. ExplanationAnxiety/ fear True Dr. Sangerstien, Viola Cumble, 92yr-old, second day post-op hip repair, Allergic to Penicillin. -Obtain chest tube tray and set-up pleurovac Document Procedure Ms. Rails states that she has not had a bowel movement (BM) in the past two days. How does the Med-surg simulator work? Establish second IV When a physician makes an incision into a body cavity just superior to the diaphragm and inferior to the neck, what body cavity will be exposed? Assist physician in physical exam of patient Biopsies were sent to determine the treatment. 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) Call Rapid Response protocol initiated His orthostasis is normalized after a second liter of NS was administered. -Elevate head of bed and place the patient on Pulse oximetry. Scenario 5 LUE: Non-pitting Pitting ___+ He chooses to go home and see the doctor tomorrow in his office. Needs frequent reminding due to determination to do things herself without assistance. Her husband and two grown children are also with her as she is prepared with gown and head cap awaiting transport to the operating room. Scenario 3 Secondary: Assess vital signs, auscultate heart, lungs, and bowl sounds. Esteem -Transport Mr. Burgundy to his room -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. Then the bus splashed into the river for a cruise. Adjust crutches Insertion site: Dry/Intact Redness Tenderness/Pain Warmth Coolness Swelling Drainage 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. IV maintenance fluids with D5 1/4 NS @ 150 ml/hr X 3 then reduce rate to 75 ml/hr. Nausea False Evaluate medication effectiveness Vital signs -Temp 99.1, BP 124/62, P 77, RR 20, SaO2 91%. Scenario 1 Wash hands The nest morning the gastroenterologist informs Mr. Gonzalez that his EGD confirmed a diagnosis of Barrett's esophagus with Dysplasia. ASA is held but morphine 4 mg was given after his GI cocktail. Safety Flexes & withdraws = 4 Urination: WNL Burning Frequency Urgency Assess toe movement and capillary refilling Respiratory Rate: WNL Tachypnea Bradypnea -Assess for fall risk No Scenario 4 Assign nursing diagnosis and plan the appropriate intervention and evaluate outcomes while working through time pressure and distractions, including random call light requests. Ineffective Airway Clearance True -Place patient on 100% O2 Vital assessment Check pedal capillary refill Provide a few chairs if possible for her family to also be comfortable Notify lead nurse/doctor Several hours later, Mr. Duncan is now complaining of nausea. Scenario 3 GI WNL. Escort patient to vehicle Increased fall risk. Offer nutrition and/ or toileting Mr. Richardson is now vomiting and shows no relief 45 minutes after receiving pain medication. : an American History, EMT Basic Final Exam Study Guide - Google Docs, Philippine Politics and Governance W1 _ Grade 11/12 Modules SY. She has been documented as being obese, new onset. DSD (dry sterile dressing), forehead laceration clean and dry intact. Safety Increased acuity, Physiological Knowledge Deficit True His partner is at the bedside asking, "how much longer will he have to wait until taken to surgery?" Skin warm dry, bruises on forehead with small laceration. Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. : 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. Chronic Sorrow False Upon entering room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." Administer pain medications Scenario 5 Dr. Small at bedside with patient and family. It was diagnosed by a portable X-ray and quickly splinted by the ER staff. -Start IV Pain Level: Increased acuity Notify Physical Therapy (PT) Water/Flush: Document results Combien gagne t il d argent ? Patient and family upset regarding dx.