Contact IV team Ask the patient when the advance directive was last updated DC DocuCare sodium if pt complains of diarrhea 7.) Fall, risk for . Scenario #5 Kathy Gestalt 9. Neurological - normal, Scenario #1 You are now preparing for d/c. Document and provide copy for Mr. Dominec to share w/ his follow up appointment tomorrow. Sensorium: Normal acuity, Physiological- Safety- Risk for imbalanced nutrition Scenario 3 Educate pt. Mr. Richardson is now pain free and questioning why he is plagued w/ recurring urinary stones. -Assess radial and apical pulse for 60 seconds Scenario 5 Assess pt's LOC VOCN300 Swift River Medical-Surgical American Career College 1. Notify respiratory therapist to begin tx Instruct Mr. Burgandy Use therapeutic understanding Wash and glove hands Reassess pt's VS's and pain level Scenario 2 Scenario #5 Pain - increased Obtain an order to insert a Foley catheter Risk for injury at home, Scenario #1 Validate NPO status Scenario 1 Take initial VS Check the foley Have family step out Pain - increased Evaluate pt understanding Use therapeutic communication to comfort pt. Mrs. Stukes's husband is not willing to help assist pt upon d/c w/ her stoma care for failed laparoscopic cholecystectomy. After 15 minutes, the pts rhythm returns, but he is still unresponsive. Give SBAR to RRT upon arrival Administer antipyretic medication Fall Risk - increased Notify HCP Deficient knowledge - Ineffective breathing pattern. Use therapeutic communication/Active Listening Notify doctor Complete bed bath Ensure chest tube, Educational - increased Remove potential harmful objects She told the nurse that she does not want a breathing tube, but her family has told the nurse by phone that they want every effort done to save her. Determine from medical Mr. Martinez was taken emergently to the cath-lab and had 3 stents inserted in his heart. Measure wound size at greatest length, width and depth using a disposable paper tape measure. Impaired mobility: True Scenario #2 Use therapeutic communication/Active listening allow expression of feelings Ask PCT 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) Psychological Needs - increased, Acute pain Scenario #5 Scenario 3 Obtain an order Scenario #5 After your AM assessment, the pt's call light goes on and she is complaining of nause, abd pain, and seeing "yellow circles". -Inspect cast integrity, capillary refill, and skin temperature Perform neuro Health Change: Increased acuity Evaluate/modify mobility plan, Physiological- Upon completion of the shift assessment, Mrs. Martinez quietly asked "my husband is telling me he is ready to get me home, that he is missing me. Provide emotional support Re-assess pt Scenario 2 She has been documented as being obese, new-onset hypertension, polyuria, and a rash on her abdomen. Hypothermia: False Mary Barkley Monitor aPTT Take vitals Risk for impaired comfort Scenario 5 Mr. Sturgess is recently dx w/ metastatic cancer of colon and he and his family have chosen only palliative care. Obtain translator Report discrepancy Initiate IV Obtain IV access Wash and glove Estelle Hatcher 15. Use therapeutic Acute pain: True Educate caller regarding HIPAA Dysfunctional gastrointestinal motility: False - Health Change - increased Psychological Needs: Normal acuity Ask Hildegard Talk to daughter that Administer Use therapeutic 2 terms. Disturbed personal identity: True She receives her AM medications including levothyroxie, diltiazem and digoxin. Evaluate learning on 100% O2 You shouldn't, "Are you okay? Notify Cath lab Evaluate caller Explain to surgeon Scenario 5 Scenario 2 Fall Risk: Normal acuity Fall Risk - increased She has been documented as being obese, new-onset hypertension, polyuria, and a rash on her abdomen. Ms. Horton did not rest well last night, and woke up frequently w/ episodes of crying. Place pt. Her HbA1C is 10%. Impaired skin integrity: True Neurological - normal, Bleeding, risk for Offer bedpan 3 terms. -Reassess wound site Scenario 2 Notify doctor Asses pt. Monitor neurovascular status assessing skin color, temp, sensation and pulses above amputation. Follow up w/ regular HCP in 1 week 4.) Check leads Ask Mrs. Pittman if she remembers the conversation w/ the physician and if she has any further questions that need to be addressed. Clean wound Assist with insertion Initiate IV Scenario 5 Serum Sodium Love and Belonging- Encourage fluids Elevate stump and reward w/ a dry clean dressing. Reinforce provider teaching You arrive in room to find Ms. Monson talking to herself. Notify the HCP of absence of Advanced Directive and the families request to intubate. Explain reason for assessment and procedure She puts her call light and asks to see a RN. Draw a repeat CBC Safety - increased Imbalanced Fluid Volume, Risk for True Apply oxygen Educate pt-STD's and pregnancy Esteem- Scenario 3 Fall Risk - increased Educate pt, - Educational Needs - increased Ensure documentation of time and events of RRT Scenario #3 Assess pt's blood glucose Begin strict Discuss his understanding - Pain - increased Deficient knowledge: False Nausea Complete chest x-ray Fluid status Fear Levofloxacin (Levaquin) 750 mg IV q 24hrs Pre-op education Scenario #5 Scenario 3 Administer anit-pyretics Evaluate understanding -Safety Social isolation: True, Marcella Como Scenario #5 Do not probe further Health Change - increased 1-Introduce and sit down by the patient's bedside Risk for post traumatic stress syndrome Initiate head-to-toe Scenario #2 Deficient Knowledge: True Scenario #3 Wash hands & assess Encourage fluids Nausea: False verbalize, Educational - increased Scenario 4 She is to notify the nurse upon return to the clinic from the lab. Hand hygiene Describe the experimental evidence that DNA is the hereditary material of bacteriophages. Don PPE Kenny Barrett, 64 years old, was admitted for observation of initial administering of BP his treatment with blood pressure of 220/124 after visiting his doctor for a routine physical. Inform his partner that everything is being done to keep him comfortable. Assess stress level Complete pre-op Don gloves Scenario 5 Notify RRT Neurological: Normal acuity Review labs Document Linda Pittmon Room 304 Glucose level? Notify charge nurse Scenario 3 Encourage Mr. Wright to include high protein snacks in his diet Notify Dr. Full assessment 3-Contact the provider and document the patient respiratory status. Fall, risk for joyce workman swift river quizlet 29 Jun. Complete full assessment Orient friend -Explain to Mrs. Barkley that you are going to change her linens Educate pt Infection, Scenario #1 Change to simple O2 face mask per HCP administer new pain medications 88 y/o female Educate Ms. Horton Tell the pt. Perform initial assessment Health Change: Increased acuity Offer nutrition/toilet Scenario #2 Encourage incentive spirometer Reinforce past Coptic mechanisms that have been effective Scenario 4 Neurological - normal -Call RRT Scenario 2 Psychological Needs - normal, - Death anxiety -Remain with the patient Obtain VS Scenario 5 Fall Risk - increased Contact HCP Provide initial report and assist RRT Esteem- Scenario #3 Kenny Barrett Administer levofloxacin -Sit at the patient's eye level and ensure they can see your lip movement and facial expression Self-actualization- We need to stop the bleeding LOC: Increased acuity Request sitter/family member to bedside Assess stool Scenario #2 Deficient fluid volume, risk for -Make sure the room temp is 84.0 F/29.0 C Listen to patient concerns It is now 2 wks later; Mrs. Smith has returned. Charge the monitor to 200 J biphasic. It is now the second day post op and his is given discharge information. Fall Risk: Increased acuity Reassess environment Scenario 1 Assess current pain Ask open-ended Connect telemetry Scenario #3 Bleeding, Risk for: True 3-Direct Chaplain to the visitor desk Past medical history includes hyperlipidemia, current elevated triglycerides, and a history of 1 pack a day smoker for the past 20 years. 3.) Check pleurovac 156 terms. Fall, risk for: True Risk for malnutrition: True Educate pt regarding condition Use therapeutic communication/active listening Assess for the abrupt how many remington model six were made joyce workman swift river quizlet Acute Pain: True Assist pt Contact radiology Electrolyte Imbalance: False Scenario 3 Place call light Deficient knowledge Impaired urinary elimination Scenario #5 Don gloves Gather supplies Health Change: Increased acuity - Infection, risk for, Scenario #1 Begin continuous chest-compressions until help arrives Scenario #4 Start O2 @ 2LNC Check surgical consent for correct procedure and make sure operative site is marked. Reinforce dressing Safety- Assist the pt. Are you okay?" She states she leads a sedentary lifestyle as a bank officer. Anxiety Infection, risk for: True Eliminate as many distractions as possible. Scenario 1 Allow visitors to enter, Educational - increased Safety- Swift River Joyce Workman scenario. Her family lives out of state, but the daughter was here for the surgery, she left yesterday. Impaired Gas exchange: False Consult wound care Sleep Deprivation False Scenario #2 Administer IV antiemetic - Health Change - increased Safety- Learn vocabulary, terms, and more with flashcards, games, and other study tools. Use therapeutic Escort pt. and legs. -Obtain second witness for signing of discharge plan, Anxiety Document Consult with MD Inspect pain location Initiate IV Deficient knowledge Wash hands and don gloves Full assessment Deficient knowledge Verify call light/bed safety precautions Notify lead nurse/doctor Pulses above the stump are palpable at 2+, skin is warm and dry. Fall Risk - increased Deficient knowledge, Scenario #1 - Anxiety Restart the IV Contact social services Ask pt. Nausea: False Administer She presses the call light w/ questions about who her RN will be and her NG-tube. Administer antipyretic meds Her pitcher has already been filled three times this shift. Restart IV Notify nursing supervisor -Consider warming the patient's hands to get an accurate reading Disturbed Sensory Perception False Isolation precautions: False Scenario #3 Use therapeutic -Notify Healthcare Provider of findings Verify call light Scenario #5 - Skin integrity, impaired Scenario #2 Apply NC O2 Check surgical consent Paroxetine (Paxil) 30mg PO everyday. - Psychological - normal, - Acute pain - Psychological Needs - increased Draw digoxin/ CMP labs as ordered -Re-position patient to up-right position and offer handwashing Deficient knowledge She was then sent to the lab for ordered lab tests. Begin list of medications Upon entering the room, you wash/glove hands. Scenario #4 Neurological - normal Notify housekeeping, Educational Needs: Increased acuity Reassure Mr. Jones -Ensure there is no fingernail polish on the pulse ox -Administer the hydromorphone hydrochloride VS assessment Scenario #5 Psychological Needs: Normal acuity Explain to her family and provide contact information Retake VS Scenario #3 5-100% O2 has not been effective in maintaining her PaO2. Provide information to Mr. and Mrs. Martinez regarding support groups, Educational Needs: Increased acuity Love and Belonging- What is going on? Offer resource assistance to caller Check VS Ensure the bed Describe the situation and what you did to deal with the situation. Therapeutic communication Contact RT Ineffective Coping: False Elevate HOB They were also concerned about the next pt going into that room and the use of the lavatory. Elevate HOB InitiateO2 Report this activity immediately to the hospital privacy officer. Neurological - Increased Make sure O2 mask is secure and free of sputum. Wash and glove hands Fall, Risk for: True. She pulled out her IV and it will need to be restarted for her IV I pro dose that is due now. Complete skin assessment Audiology changes, risk for Therapeutic Communication Scenario #1 Explain to the pt. Wash hands Notify charge nurse that d/c will probably not occur today. Provide morphine Hopelessness: True Use therapeutic communication/Active Listening Comfort the pt Pt was admitted yesterday afternoon w/ HTN, BP 178/90, P 88. Decisional conflict: False - Deficient knowledge Infection, Scenario #1 Construct dietary consult She was admitted yesterday for stabilization of her glucose levels, and assist her with lifestyle modification. Scenario 1 Scenario 3 -Check the chart for the presence of a DNR order to provide the code team Acquire daily weight VS assessments Upon enter the room, she asks you if she will be able to drive when she gets home tomorrow. Ask Mrs. Workman for 24-hour diet Disturbed body image: False Remove NG-tube Full assessment Provide introductory Mr. Sturgess is uncomfortable w/ experiencing urinary frequency that keeps him from resting Pt has a hx of COPD, HTN, DM II, and a recent MI. Give verbal report Scenario 5 Administer new Approach resident Take VS not Obtain blood (culture #1) Continue to encourage Impaired Physical Mobility: True Ineffective Breathing Pattern: False -Tell the patient that dressing must be changed, 1-Put a mask on yourself Psychological Needs - normal Infection, risk for, Scenario #1 Wash hands Present health assessment Remind pt. Pain - normal Check proper Perform post-op Explain the necessary At 2200, you enter the room and the pt states pain is now 10/10 after not having any pain for 3 hrs. Ineffective self-health mgmt: False . Wash hands Leave the break room Call for CODE-blue Follow HIPAA Determine onset of confusion Be honest with Cameron Apply triple abx ointment to edges of wound each dressing change 3.) Ask the charge nurse You begin his assessment, and he falls back in the bed and becomes unresponsive. Marcella Como is now more talkative and shares with you that she is going to cooperate and wants to press charges against the assailant. D/C instructions Health Change: Increased acuity Reassess VS Administer rectal Encourage Mr. Jones Health Change - increased Perform comfort Request CNA Scenario #4 Discuss support groups, Educational Needs: Increased acuity Impaired home maintenance mgmg r/t client or family: False Wash/glove After 3 hours Ms. Monson is now crying asking to be released from these restraints and for someone to take her home. hali149 . why you are doing Repeat 1mg atropine Sensorium: Increased acuity, Physiological- Document results She appears short of breath when talking. Nausea, risk for Full assessment Scenario 5 Explain reason for medication to verbalize Apply fall risk bracelet Provide comfort Use therapeutic communication/active listening Pre-medicate for pain w/ prescribed medication Acute Pain: True Administer Valium Document Reinforce dressing Verify call light/ bed safety precautions Evaluate medication Administer Epoetin Encourage Mr. Clinton, Educational - increased Perform hand hygiene Apply new dressing Educate family regarding active listening and open communication Pt received furosemide Lasix 20mg, IVP x2, on Claforan Q4, and on sliding scale insulin. You enter patient's room. Contact HCP Perform a focused assessment Notify lead RN Psychological Needs - increased Obtain VS Document responses. 1-Listen to patient's concern Explain to Mr. and Mrs. Martinez the disease recess following a MI -RRT has arrived, coordinate patient care for a stat VQ scan Update pt on d/c changes Dysfunctional Gastrointestinal Motility: False She was admitted yesterday for . Assess VS Educate pt. Your coworkers are asking you questions about mr. Dominec. Attempt to orient on O2 Report current Ask the pt if she has had the procedures previously -Orient patient to bathroom with specifics Educational Needs: Increased acuity Love and belonging Scenario 1 Pain - increased Scenario 4 Ensure no one in the room is touching the pt or the bed and cardiovert Scenario 3 The accompanying absorbance data are for 8.00 \times 8.00 10^ {-5} \mathrm {M} 105M solutions of the indicator measured in 1.00 1.00 -cm cells in strongly acidic and strongly alkaline media. Place pt. Allow family to remain Anxiety: True Scenario 2 - Impaired tissue perfusion statement Escort patient Encourage use of IS If gastric reflux Orient pt. Complete full assessment Reassure pt. 37. Infection, risk for, Scenario#1 He has bilateral lower lobe atelectasis w/ bronchial vesicular wheezing. Provide education regarding HF Explain that Radium-223 Scenario #5 Inspect site Assess for bowel sounds - Imbalanced nutrition Safety Fall, risk for Announce to CODE team that you are ready to cardiovert Have pt put on a mask Introduce hospital liaison, Acute pain Sterile NS wet-to-dry dressing changes daily 2.) -Wipe down chair with disinfectant - Impaired physical mobility - Safety - increased, - Pain, acute Health Change - increased Squeeze the contents Obtain blood (culture #2) Three days after d/c, you receive a phone call from Mrs. Stuke's neighbor, who is helping take care of her. Scenario 4 Sign additional She was admitted yesterday for stabilization of her glucose levels and . Notify the charge Evaluate understanding Read PT to apply Employ therapeutic communication: present reality Medicate Scenario 5 Assess toe movement Psychological Needs: Increased acuity, Physiological - Pre medicate Morphine Sulfate 4mg IV 15 minutes prior to dressing change 3.) Scenario 5 Scenario 2 Remain w/ pt Advise pt. Educated pt/family Insert foley Check IV Scenario 2 Initiate IV Obtain translator Scenario #1 Grieving: True Check foley Assess pt's understanding, Bleeding, risk for Full assessment Re-assess pt Seek clarification Notify HCP Acute Confusion True Educate pt Bleeding: False Sensorium - normal, Acute pain Health Change - increased Deficient knowledge This survey aimed to determine the frequency and symptoms of dysmenorrhea, as identified by differen. -Assure patient that she is safe in the hospital, and you will not leave her Document all findings Scenario 4 Discuss follow up with his doctor. He is now in V-tach w/ a weak pulse and BP 70/40. Reinforce to the pt. Scenario 4 Fall Risk - increased Peripheral neurovascular dysfunction: False Start another IV Inform Mr. Burgandy Swift River Medical-Surgical. Obtain & verify Study with Quizlet and memorize flashcards containing terms like Linda Pittmon, Kenny Barret, Joyce Workman and more. Skin integrity at risk Assign a UAP Complete neuro - Disturbed personal identity IV 20g, left forearm, NS 125ml/hr Could he have another heart attack? Bleeding, risk for Interviewing pt. Perform neuro assess Assess understanding through teach back Vitals? -Request a volutrol/metered indwelling urinary catheter bag when they return form the OR. You are entering the room for the first time. All 5 toes on the right foot are necrotic, absent pedal pulses, skin cold to touch, appearance dry, cracked and black up to mid-calf. Scenario #3 Documentation immediately. & VS, Educational - increased Scenario #5 Pain - increased Change IV fluids to 75ml/hr 8.) Prepare for heparin Use therapeutic Deficient knowledge: True Obtain 16 gauge angiocath -Assess peripheral vision Call HCP for change in health status and receive orders for anxiety medication Her daily medications at home include: Prednisone 5 mg, Furosemide 20 mg, and ASA 81 mg daily. the PCT is requesting to be relieved as the pt keeps pulling at the PCT's mask to see who she is. Assess for bowel Verify call light/ bed safety precautions Remove NG -She experienced life threatening wounds with 2 gunshot wounds, including one to the shoulder Scenario #3 Education of F/C procedure Ineffective peripheral tissue perfusion: False Scenario 5 Therapeutic communication Doctor orders 1.) Scenario 4 Scenario 4 Document Assess stress level Evaluate/modify plan of care Scenario 2 Hopelessness: False. Offer to contact family for HCP. joyce workman swift river quizlet. Apply O2 Scenario #3 2. Begin strict I&O Reposition HOB to semi-fowler's Day 2 admission, Thomas Richardson is complaining of severe pain and is now begging you for some relief; states pain scale 10/10 Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Insert F/C 1-Obtain a new IV site Health Change: Increased acuity Medicate for pain Visual assess Fall Risk - increased Ineffective Renal Perfusion, Risk for True Inform admitting physician Establish large IV Evaluate the following expression containing percent. Administer oxygen Wash & glove This morning, at shift report, she states that she is scared to leave the hospital after the shooting incident. She was asymptomatic upon arrival. Perform dressing change Explain HIPAA Deficient Knowledge: True Provide the pt. Allow family She has been documented as being obese, new onset hypertension, polyuria, and a rash on her abdomen. Safety- Imbalanced nutrition Fatigue: True Scenario 3 Evaluate understanding Scenario 4 Noncompliance: True Evaluate pt. Scenario #2 Reassess pain Allow for non-compliance to Do not disturb the pt Review plan Pain - normal Maintain strice Impaired mobility: True -Assist patient in performing hand hygiene Notify HCP Document Pain level: Increased acuity Hold next dose Place the syringe in a biohazard bag and place a pt id label on bag Asses for mediastinal shift Remind surgeon & staff -Inform Mr. Goodman that his girlfriend called about his status. -Mobility Teach pt. Comfort the pt Reemphasize to pt. Start a saline lock Obtain a sitter/UAP Wash/glove hands Esteem- Complete incidence report, Educational - increased Scenario #4 Sensorium: Normal acuity, Physiological- Scenario #2 -Perfusion Should I be concerned about having sex w/ him? Have pt. Ms. Horton's wounds are now stable enough to be discharged home w/ the following orders 1.) Scenario #3 Nausea: False Scenario 4 Health Change: Increased acuity Have the pt. Scenario 1 impaired comfort An empty syringe is noted in the bed. Perform rapid assessment Set her up Reassess pt. Scenario #4 -Position the patient in high Fowlers if tolerated. Encourage positioning Discuss support, Acute pain She is 2 days post-op. Knowledge deficit: False Perform full assessment Label the sporophyte plant stages of the life cycle. 4. Teach pt. Swift River Maternal-Newborn; Deanna Concept Map Assignment 1; Scenario 5 Remind CODE team to stop CPR and check for pulse Q5 minutes Explore new ways Other Quizlet sets. Have pt. - Impaired comfort Don new gloves She is super morbidly obese with a BMI of 52, Ht, 5'3", Wt, 293lbs. Acute Pain False Offer full AM bath joyce workman swift river quizlet - BridgeLight Insurance Deficient Fluid Volume: True Request time she can arrive and staff to help w/ txf Obtain bedside Scenario 4 Sensorium - normal, Impaired coping Anxiety: False -Patient Education Reassure patient of options Wash and glove The pt states, "I am sick to my stomach and feel like I have bugs crawling all over me!!!" Readiness for enhanced immunization status: True Provide emotional Full assessment Ask surgeon Document results and findings Offer nutrition Expert Answer. Wash and glove hands She is also anxious as a result of recent surgery. Scenario 5 He is still unresponsive. Assess respiratory Serum Potassium Ensure continuous Contact head RN or supervisor in the OR to evaluate new situation. Check blood glucose Scenario #2 Prepare pt. Ask PCT to secure mask better, and inform her that there is no replacement for her. Ms. Gestalt capillary refilling is now 6 seconds below cast site, extremity is swollen and cold to the touch Psychological Needs - normal Provide emesis basin/cloth Reassure pt. Psychological Needs - increased Vital assessment Allow pt. Impaired comfort Administer the medication Concepts of Nursing IV 80% (5) 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. Start studying swift river med surg. Pain Level: Increased acuity Assess understanding through teach back. Educate Mrs. Workman Neurological: Increased acuity Contact CC's uncle Do not probe Reassess VS & obtain UA Scenario #1 RBC Health Change - normal Document results Scenario #2 Explain to Mr. Dominec Assess VS Administer pain medications Document results Deficient knowledge Allow husband Document teaching - Drug therapy, Scenario #1 to remain Assist Mr. Jones Ask parents Arthur Thomason 16. Disturbed energy field Teach pt about safety when getting out of bed Scenario 3 Release restraints 4-Stop the conversation immediately swallow Evaluate understanding Scenario #5 Complete neuro Obtain and provide Vitals? Ms. Gestalt is second day post-op and has requested to get out of bed and to ambulated to bathroom. Measure wound size Neurological - normal, Scenario #1 Diarrhea: False Seek clarification Present health assessment including BP and LOC and dressing. Health Change - increased Provide comfort measures Contact dietary consult PsychologicL Needs - increased Nutrition: True Pain Level: Normal acuity -Remind students of HIPAA policy, and report observations to the Nursing professor Take VS - Constipation, risk for Offer to assist He is anxious that he will forget to take it or take the wrong dose. arrival Swift River Linda Pittmon scenario. Perform a focused assessment Scenario 1 She is 85 years old and has a history of osteoarthritis and cataracts. Contact HCP, Educational - increased Place the syringe Give tylenol Notify lead RN Concepts of Nursing IV 100% (2) Deanna Concept Map Assignment 1. Orient pt and husband to the unit Safety- Scenario #3 Explain to pt. Scenario #4 Review medication Acute Pain: False Request order for telemetry Check monitor Ensure cardio-pads are in place anterior chest and posterior back Communicate w/ the pt therapeutically Ms. Barkley continues to deteriorate and is shouting for her family. Keep Mr. Clinton Scenario 5 The pt continues to be combative while attempting to initiated the CPAP trial. LOC - normal Fluid & electrolyte imbalance, risk for Don clean gloves and removed the old dressing. Risk for impaired comfort: True Scenario 2 Administer the medication Notify PT Initiate anti-psychotic meds Mrs. Smith shares w/ you that even though she signed the operative consent she was not sure if this was the right surgical procedure for her. Assess pt's ABCs Complete physical Scenario 1 Monitor for adverse Provide initial Chronic Pain: False Educate pt Scenario 1 Please fill in any remaining missing answers, and let me know if anything is incorrect. Assess pt's anxiety Initial assessment She is requesting the names and home phone number for the wound care nurse who saw Mrs. Stukes while she was an inpatient. -Grief Notify charge nurse The nurse repositioned the pt to the left side to decrease pressure on the sacrum and rt heel. Full assessment Scenario #4 Document results Call RRT Dotty Hamilton Room 301 Dotty Hamilton 52 y/o female who has been admitted for bariatric surgery. Wash & glove Psychological Needs - normal CK-MB 6.8 Explain to Roger Fear: False 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. The CNA reports the blood pressure was 130/86 an hour ago Continue frequent VS, Acute pain Attempt de-escalation strategies chemistry. Impaired skin integrity: False Wash and glove hands Scenario #5 Shae_Quinn9. Check for cognition Ms. Hatcher is second day post-op and has a NG tube set to gravity drainage only. - Sensorium - normal, - Fatigue Scenario 5 Grieving: False Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Peripheral neurovascular dysfunction: False, Kenny Barrett Linda Pittman Monitor for adverse effects Pain reassessment Obtaintelemetry Upon entering the room, the pt is crying and asks when will the medication fix her heart. Post op day 3 time for dressing change stump. Inform the pt. Document Educate pt. Fear: True Scenario 5 Contact charge nurse HCP orders 1.) Pain Level: Increased acuity Psychological Needs: Normal acuity, Physiological Check monitor Impaired mobility: True Scenario #2 Fall Risk - normal Educate pt. Sleep deprivation: False Scenario 4 Proved additional teaching VS are deteriorating, BP 90/58, P 116, R 28, PaO2 85%, T 102.0. Promote open Scenario #5 Educate pt. Bleeding, risk for: True She was, asymptomatic upon arrival. Prescribed medication Death anxiety: True Scenario 5 Eliminate as many Scenario #5 Offer assistance Contact nursing supervisor Scenario 1 Review current Full assessment Pt. -Contact the Provider to tell them the patients pathology report has returned, and Mr. Clinton is anxious to know the findings of his pathology report Notify social services Review pain medication order
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