Recent chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes. Respiratory Rate: WNL Tachypnea Bradypnea Yes You arrive in room to check on her, after washing hands. After 3 hours, Ms. Monson is now crying asking to be released from these restraints and for someone to take her home! Evaluate understanding. Physiological Wash and glove hands His partner is not with him at this time but will arrive soon to facilitate his discharge home. Palliative care. Notify lead nurse Impaired mobility: False Scenario 3 Sarah Getts Roger Clinton, 57-year-old male construction worker arrives at 0600 to be prepared for a partial thyroidectomy to determine if he has cancer. The patient has a pneumothorax that requires a chest tube placement. Linen Change Swift River MedSurg 1.pdf - MED-SURG SCORE: 100 TIME Provide comfort in pre-surgical room Mr. Dominec. Robert Sturgess Scenario 1 Mr. Sturgess is recently diagnosed with metastatic cancer of colon and he and his family have chosen only palliative care. Sleep Deprivation False Nutritional Intake: Adequate Inadequate BMI: Physical Mobility, Impaired True Re-assess patient Hep-Lock in place left AC. Breath Sounds: Clear bilaterally. Mr. Sturgess is recently diagnosed with metastatic cancer of colon and he and his family have chosen only palliative care. Kathy Gestalt Scenario 4 Impaired Mobility True The emergency bathroom light goes off and the nurse finds Mr. Greer on the floor in the bathroom. He requests no visitors at this time, but later asks for his family to be called to discuss a plan of care. Acquire daily weight and food intake Nursing questions and answers. Scenario 2 The sister of Mr. Mancia calls from home to speak with you. 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. 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. Non-significant past medical history. Skin warm and pale. Health Change Increased acuity -Restart the IV and draw CBC Temp Scenario 4 Last Bowel Movement: Date: _____________________ Constipation Diarrhea/Loose Other: Vital signs -Temp 99.1, BP 124/62, P 77, RR 20, SaO2 91%. Employ therapeutic communication: present reality Cardiovascular has pacer with rate of 82bpm on demand. Reassure patient of options -Attempt to orient to person, place, and time Color:__________ Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. -Notify charge nurse of patient's deteriorating condition Scenario 1 Mr. Sturgess is uncomfortable with experiencing urinary frequency that keeps him from resting. Scenario 4 The patient has been scheduled for an EGD today and has an order for Omeprazole (Prilosec) and Carafate (sucralfate). Fall, risk for: True Evaluate learning Chronic Sorrow False Iron forms a sulfide with the approximate formula Fe7S8\mathrm{Fe}_7 \mathrm{~S}_8Fe7S8. Dr. Altace, Educational Needs Increased acuity Document Procedure Present health assessment including B/P and LOC and dressing. No known allergies (NKA). -Assess patient's ABC (airway, breathing, circulation) Tom Richardson Scenario 3 Obtain translatorT Glasgow Coma Scale 0-15 Musculoskeletal Vital signs -Temp 98.8, BP 102/76, P 102- irregular, RR 22, SaO2 90%, cardiovascular on telemetry with Sinus irregular rhythm. The surgeon believes that the surgery was successful but recommends the patient have chemotherapy and radiation postoperatively. Dr. Rondeau, Educational Needs Increased acuity Respiratory Effort: Relaxed, Regular, Non-labored Pursed lip breathing Labored Regular diet. Call Rapid Response protocol initiated In the interim, start an IV and start infusing Ringers Lactate. Fear True Place call light and check bed for safety The patient has a Foley catheter in place and is reporting 8/10 incisional pain and he is asking why his throat is sore. -Inform patient to not get out of bed without assistance and place call light in reach She has been admitted to the floor with complaints of numbness in her right foot and ankle. Patient, and family upset regarding dx. Palliative care. Sa fortune s lve 2 216,00 euros mensuels -Assess patients' pain and rule out cardiac pain. Cross), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Mark Klimek Blue Book Study Guide, 200 pages, Perspectives in the Natural Sciences (SCI100), Principles of Business Management (BUS 1101), Electrical Machines and Power Electronic Drives (E E 452), Methods of Structured English Immersion for Elementary Education (ESL-440N), Pre service firefighter education and training (FSC-1106), Advanced Medical-Surgical Nursing (NUR2212), 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), Chapter 1 - Summary International Business, Death Penalty Research Paper - Can Capital Punishment Ever Be Justified, Skomer Casey, BIO 140 - Cellular Respiration Case Study, English 123- 3-4 Assignment Submission- Annotating Your Sources, Ch 2 A Closer Look Differences Among the Nutrition Standard & Guidelines & When to Use Them, Greek god program by alex eubank pdf free, Logica proposicional ejercicios resueltos, 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. Verbal command = 3 Imbalanced Nutrition: True Chronic Confusion False Begin post op education for day one Scenario 4 Grieving False Impaired Skin Integrity False Neuro WNL alert and cooperative. Scenario 5 Her husband who is present states, "I thought it was just a lumpectomy she was having this morning." Inspect cast site Yes Productive Non-productive Describe Sputum: _______________________ -Ensure IV is patent, Lithia Monson 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! Nathaniel Gonzalez Bowel sounds: Active, Hyperactive, Hypoactive, Absent (listen for full 5 minutes) He also has a history of hypertension and takes Tenormin (Atenolol) and Atorvastatin (Lipitor). Dr. Roopes, Estelle Hatcher, 31yr-old, r/o appendicitis, 1st day post-op appendectomy; No known allergies (NKA); Vital signs - Temp 101.2, BP 108/74, P 92, RR 20, SaO2 99%, alert and cooperative. Impaired Mobility True No known allergies. Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Notify lead nurse/doctor However, these abnormal cells do not have the capability to spread to other parts of the body. Psychological Needs Normal acuity Isolative, appears fearful, crying, and refusing to see her husband. Ineffective Airway Clearance True Clinical 2 Flashcards | Quizlet Day 2 admission, Thomas Richardson is complaining of severe pain and is now begging you for some relief; states pain scale 10/10. Skin cool to touch and appears pale. I need to be reporting!" Safety No Known allergies (NKA). Esteem Anxiety True Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. John Duncan Full assessment including both lying/standing Ms. Gestalt is second day post-op and has requested to get out of bed and to ambulate to bathroom. Document results IV D5 1/2 NS @150ml/hr. Deficient Knowledge False Oriented to: Person Place Time Tap patient and ask, "Are you okay?" Skin warm and, dry, all vital signs in WNL except 115 pulse, which is normal for him. 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. The Elbe River - hamburg.com Document findings Start secondary large bore IV line Scenario 1 Obtain translator Scenario 1 Wash hands NKDA Assessment The client vital signs are: Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%, Neuro WNL alert and cooperative. Take vital signs before leaving the hospital again. Administer antipyretic meds -Complete neuro checks as ordered They were also concerned about the next patient going into that room and the use of the lavatory. Administer antipyretic medication Self-Care Deficit False DSD (dry sterile dressing), forehead laceration clean and dry intact. Mr. Sturgess is now declining, and family members are requesting to remain in room past normal visiting hours. Senario 4 Obtain recent chest X-ray reports and recent ABG's for physician to review Decreased cardio tissue perfusion: False You question her while reviewing her operative consent and determine that everything is correct. -Ask the patient to verbalize understanding of teaching and reassure them that yourself or any member of their care team will be available to answer questions. Pain Level: Increased acuity Ambulates with assistance. The patient describes this pain as a heavy pressure with intermittent stabbing. -Advise patient not to get up and walk on his own Scenario 4 Oral Mucosa: Tongue: Teeth: Scenario 2 Hep-Lock in place left AC. Swallowing: Intact Dysphagia Aspiration Precautions Safety- -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. 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 . 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. Love and Belonging palliative care. Educational Needs Increased acuity Upon entering room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." -Reinforce to the patient to not get out of bed 97.4, Resp 16 and Pulse Ox 94%. Mr. Duncan's wife meets you in hall asking what she could bring her husband to eat from home. Safety Electrolyte Imbalance, Risk for True Document results Grieving: False You determine to apply the restraint now. -Advise sitter to notify nurse when leaving the room Perform neuro assess Scenario 2 Document results The tour started nicely through the new area Hafencity but then continued to the area under development and a very desolate district of Hamburg. Apply nasal cannula Scenario 5 No known allergies (NKA). His left humerus is fractured and splinted. Document results Flexes abnormally = 3 Nutrition True Educate patient/family -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 Hafencity Riverbus (Hamburg) - All You Need to Know BEFORE You Go Why is cysteine such an important amino acid for defining the tertiary structure of some proteins? 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.) . Date of insertion: _________________________ Date of dressing: _________________________________ Bowel Movement Total: x________________, Hygiene Times Failure to Thrive False. Scenario 1 Inform and educate spouse of dietary orders Psychological Needs Increased acuity Ask patient to explain to you what procedure she was expecting to have this morning. Vital assessment -Elevate head of bed and place the patient on Pulse oximetry. Senario 2 Scenario 3 jessdevan. The bed arrives tomorrow. Non-significant past medical history. Wash and glove hands Fall Risk: Increased acuity No known allergies (NKA). Safety Encourage fluids and fiber diet The provider explains that it is a pre-cancerous stage in where the cell develops abnormal features.

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