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Scenario 4 Odor: __________, No Teach Cameron. Infection, Risk for False Encourage fluids and fiber diet Include patient condition change in shift report 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. NURS 320 Med_Surg_Swift_River **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 Oriented to: Person Place Time Reorient Patient to person, place, & time Non-significant past medical Hx. No known allergies (NKA). Scenario 1 Grieving False -Notify HCP of fall, complete incident report Tube Feeding: Type:_________________________ Amount/Rate: ________________________ Bolus/Infusion Vital signs -BP 124/82, Temp 98.2, P 84, RR 22, SaO2 96%. Pain Level Increased acuity RLQ: RUQ: LUQ: LLQ: Failure to Thrive: True. Ms. Rails was medicated with hydrocodone 5 mg PO two hours ago and is now complaining of pain (8/10 pain scale). Evaluate understanding. Decreased cardio tissue perfusion: False The patient is being prepared for discharge and his IV has been removed. Self-Actualization Psychological Needs Normal acuity Impaired Skin Integrity False Establish second IV Ask patient to explain to you what procedure she was expecting to have this morning. He also states he is feeling weak. -Complete head-to-toe assessment while patient is on the floor. Stoma status: Pink-Red/Moist Dusky Retracted Excessive bulging Scenario 5 You arrive in room to find Ms. Monson talking to herself. -Discuss effectiveness of sitter Provide Operative summary of type of procedure, IV fluid and pain status. -Discuss with sitter that patient needs continual observation Ineffective Coping False Scenario 2 Last Bowel Movement: Date: _____________________ Constipation Diarrhea/Loose Other: Senario 4 His partner is at the bedside asking, "how much longer will he have to wait until taken to surgery?" Hx of dementia, from nursing home, fall one day ago. The heartburn has become worse since he started treatment for his URI. Scenario 5 -Reinforce the risk if patient has not been NPO and ask the patient when the last time they ate. Release restraints/full range of motion Document results. -Reassess patient q 5 minutes until awake, then 15 minutes until they are fully awake (not Drowsy). Educate patient regarding patient care Apply oxygen -Transport Mr. Burgundy to his room Cryotherapy, which uses an endoscope to apply a cold liquid or gas to abnormal cells in the esophagus. Kathy Gestalt, 33yr-old, Dx- second day post-op open right Tibia/Fibula fracture, plaster cast in place on right lower leg. 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. Students will form a preliminary assessment based on reported assessment data for medical surgical patients in a virtual clinical environment. Raspberry and Cream Cheese Stuffed Blueberry French Toast with Ozery. The patient was placed on 2 L O2 NC, EKG monitoring to include a 12 lead, Pulse Oximeter. Scenario 5 Check physician orders Health Change Increased acuity Educate patient Ambulates with minimal assistance. They were also concerned about the next patient going into that room and the use of the lavatory. Senario 2 The impedance per phase in the load ist 14+j1214+j 12 \Omega14+j12. Scenario 3 Fall Risk Increased acuity Continue.Robert Sturgess Room 305 Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. Mr. Thomason is anxious and is obviously worsened from the shift before in overall condition. His wife tells the nurse that he seemed very distant and did not want to talk much. Mrs. Pittmon states she has had numbness for years but "now I can't . Scenario 4 Sa fortune s lve 10 000,00 euros mensuels Regular diet. RUE: ______________ LUE: ______________ Senario 1 Impaired Mobility True Safety- Scenario 2 Check PRN pain order He is aware that he may not have an erection and may need depends for bladder incontinence. Hopelessness False. Begin post op education for day one Non-significant past medical Hx. Assume role in response team of documenter Breath Sounds: Clear bilaterally. Document results Tubes: None Salem Sump Nasoduodenal PEG J-Tube pH: ______ Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. ExplanationAnxiety/ fear True Health Change Increased acuity Scenario 4 Health Change Increased acuity Flexes abnormally = 3 Patient and family upset regarding dx. Senario 3 They wanted to know and pressure you for the information. Ms. Gestalt capillary refilling is now 6 secs below cast site, extremity is swollen and cold to the touch. Acute Confusion False Fall Risk: Increased acuity Scenario 1 He has a history of hypertension and is not compliant with medication. Stay with patient for surgeon's arrival to explain intended surgical procedure -Recheck Tilts after the NS bolus is complete.T Fall, risk for: False Deficient knowledge: True 50% intake. Wound clean dry and intact. Decreased Cardiac/perfusion False Pulse In reassessing Ms. Monson, her vital signs are: BP -106/82, Temp-98.2, P-106, RR-18, SaO2-88. Scenario 1 Sa fortune s lve 1 900,00 euros mensuels : an American History (Eric Foner), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Combien gagne t il d argent ? Deficient Fluid Volume False Scenario 5 Vital signs -Temp 98.4,BP 178/105, P 112, RR 28, SaO2 94%; Neuro- WNL's. Acquire daily weight and food intake -Explain to the patient that he has a procedure, and he cannot eat. Chronic Confusion False Dr. Small at bedside with patient and family. Scenario 1 -Medicate for pain Discuss his understanding about the plan of care. -Complete incident report. Use therapeutic communication/active listening Acute Pain True Mr. Dominec had his surgical procedure and is doing great. Electrolyte Imbalance False 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. Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. Severe pain (10/10) medicated q 30 minutes x4 with IV Morphine 2mg with little relief. Expresses fatigue, fear, concern, and desire for recovery. His original lymph node biopsy was negative. Palliative care. Scenario 1 -Draw a repeat CBC per HCP order to determine current Hemoglobin status Abdominal Pain: Non-tender Tender/Pain Describe: c/o headache- medicated with Lortab 5mg PO at 0900, takes Lomotil 10ml PRN q 4 hours last dose at 0834. Document results A GI cocktail was administered, and the patient stated that it decreased his pain to a 6/10. Evaluate caller understanding Listen to patient concerns Scenario 2 Skin integrity, impaired True -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. Chronic pain: True Bowel Movement Total: x________________, Hygiene Times Health Change: Increased acuity Offer assistance in providing more information about treatment options for newly diagnosed AIDS patients. Swift River Clinical Practice Chamberlain University Expert James Moore Category: Nursing Description Full Document Jose Martinez Room 301 Jose Martinez, Jose Martinez, 43- year old male experiencing chest pain while watching a state rival football game earlier in the evening. His overall health is good, and he has known he has been HIV positive for the past five years. 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. Place patient on PCA pump Scenario 3 Report to charge nurse/ head nurse the need for staff education. Ms. Gestalt is second day post-op and has requested to get out of bed and to ambulate to bathroom. Health Change Increased acuity Impaired Mobility True Impaired home maintenance mgmg r/t client or family: False When you arrive to room 4, you are told to assume the care for the patient and get ready to transport them to the floor ASAP. Why is cysteine such an important amino acid for defining the tertiary structure of some proteins? Skin warm and pale. Perform neuro assess You notify the charge nurse that you have never taken part in inserting a chest tube. Hx of dementia, from nursing home, fall one day ago. Evaluate patient understanding student name date: nur 113 assessment swift river patient: robert sturgess handoff robert sturgess, 81 years old, metastatic ca of colon, hx of diabetes. Impaired comfort: True -Attempt to orient to person, place, and time Scenario 2 -Assess patients' pain and rule out cardiac pain. Education of Foley Cath Procedure -Elevate head of bed and place the patient on Pulse oximetry. Neuro WNL alert and cooperative. Senario 3 All our products can be personalised to the highest standards to carry your message or logo. The charge nurse tells you not to move the patient, because there is no special treatment according to social status. Remind the nursing staff that the patient is NPO. Infection, Risk for False Bleeding, Risk for True You question her while reviewing her operative consent and determine that everything is correct. Obtain translatorT Mr. Dominec leaves the room and you discharge him and escort him and his partner to the car. No known allergies (NKA). His coughing, to clear his airway, appears ineffective. Scenario 1 She receives the pre-op medication. Anterior: ___________________________________ Posterior: ____________________________________ 1Perform full assessment and provide anti-nausea medicine. Check PRN pain order Leave to break room and not continue in conversation. Encourage fluids/fiber/ambulation 2. D/C plan- decrease pain and restore normal gait. Assess intake and output and possible reasoning He is emotionally distraught and is insisting that he be allowed to report what is going on from the ER. His, Joyce Workman Room 303 Joyce Workman Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Where is my camera man!! You arrive in room to check on her, after washing hands. Scenario 4 Vital signs are: B/P 112/78, temp. Robert Sturgess 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. -Provide a diversional activity to pass the time while waiting on the HCP and inform wife that the HCP will be coming soon No known allergies (NKA). Scenario 1 The patient will be discharged today, and he will be ordering new prescriptions. The patient has a Foley catheter in place and is reporting 8/10 incisional pain and he is asking why his throat is sore. Ms. Cumble states that she has not had a BM for three days. ADA diet, intake 25%. After 3 hours, Ms. Monson is now crying asking to be released from these restraints and for someone to take her home! Elevate Extremity Document results. Gown and mask Ann Rails Vital sign Temp 98.4, BP 136/78, P 72, RR 20, SaO2 97%. He has been taking his HIV medication daily. Radiofrequency ablation may be recommended after endoscopic resection. Psychological Needs Increased acuity Radial: ____ + Bilateral Other: _____________ RLE: Non-pitting Pitting ___ + Escort patient to vehicle Risk for Infection True He is complaining of pain in his left arm, and pain in his left chest when he tries to take a deep breath. 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. Your responsibilities are: Scenario 1 -Place patient on O2 Nasal Canula Dx- urinary stones with 3 episodes/5yrs. Scenario 3 Acute Pain True Document pt's statements. 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 The charge nurse tells the nurse to take Mr. Burgundy to the floor, because his room is now ready. Decisional Conflict False Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. Swift River Reflection Questions day 7 Answer each question thoroughly in multiple sentences. -Assess patient's understanding of the teaching and discuss home support, os de la main et de la ceinture pelvienne, Julie S Snyder, Linda Lilley, Shelly Collins. Shock, Risk for: False He is emotionally distraught, and is insisting that he be allowed to report what is going on from the ED. Generalized weakness, blood tinged urine and severe pain upon urination, GI- n/v. Two housekeepers, who were refusing to clean the room, are in the break room. He told the nurse that he has had some changes in his bowel habits and his stools have been very dark. Mr. Greer has just been visited by his wife. Skin warm dry, bruises on forehead with small laceration. Failure to Thrive True. No Known allergies (NKA). Scenario 5 Alert and cooperative. Scenario 4 -Ensure there is suction in the room, and check Imbalance nutrition: True Opening Title Production company Cast and crew Genre J A N U A R Y 2: The Killing of John Lennon: IFC First Take: Andrew Piddington (director/screenplay); Jonas Ball, Krisha Fairchild, Gunter Stern, Gail Kay Bell, Mie Omori, Robert C. Kirk: Crime, Drama: 4: One Missed Call: Warner Bros. Pictures / Alcon Entertainment / Kadokawa Pictures: Eric Valette (director); Andrew Klavan (screenplay . He chooses to go home and see the doctor tomorrow in his office. Obtain translator Use therapeutic communication/Active Listening Explain to physician what interventions you have recently initiated He does not have an IV nor is he on oxygen. 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. 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. 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He has been ruled out for an MI. Esteem Upon entering the room, you find Mr. Sturgess is quiet, appears tense and rigid but states, Offer nutrition/toilet Scenario 2 Senario 3 He is questioning the nurse as to why he has been admitted for heartburn. Assess toe movement and capillary refilling Explain to her family and provide contact information. -Explain procedure to the patient Upon assessment, you determined that she is confused to person, time, and place but is easily directable. Senario 1 -Reinforce to the patient to not get out of bed Color:__________ -Ask Mr. Burgundy to lower his tone as it can be disturbing to other patients Educate patient Infection, risk for: False. Chronic Pain False Assume that the oxidation state of sulfur is 2-22 and that iron atoms exist in both +2+2+2 and +3+3+3 oxidation states. Clinical 2. Wash and glove hands Mr. Richardson is now pain free and questioning why he is plagued with recurring urinary stones. Teach patient about safety when getting out of bed Safety Increased acuity, Physiological Tap patient and ask, "Are you okay?" Evaluate understanding He is a local TV news reporter that was filming an event at the county fair when there was an explosion. Dr. Donofrio, Chronic Pain, Risk for constipation, impaired nutrition, anxiety, fear, grieving, hopelessness, powerlessness, Daily Flowsheet & Physical Assessment, Vital Signs Intake & Output Pain Level Increased acuity How was this Respiratory Assessment -Complete initial post-op assessment Vital Signs: B: 160/92, P: 96, R: 22, SpO2: 98, T: 98.9F, 37.1C. Scenario 4 Eye opening Spontaneous = 4 The nurse performs tilt test, Patient vital signs lying flat, BP 118/62, P 92, R 20, T 98.5, SpO2 97. Check pedal capillary refill Scenario 5 Bleeding False He replies, "six times in the past four hours". Evaluate understanding Reapply restraints Patients within the Swift River Online Simulators Med Surg - Patients SROL Med Surg Female and Male Patients Female Male Ann Rails Carlos Mancia Estelle Hatcher John Duncan Kathy Gestalt Robert Sturgess Lithia Monson Tom Richardson Marcella Como Ramona Stukes Sarah Getts Viola Cumble Dosage Calc - Patients SROL Dosage Calc Female and Male Patients Senario 2 Endoscopic resection, which uses an endoscope to remove damaged cells to aid in the detection of dysplasia and cancer. The charge nurse tells you to get the Mr. Burgundy to the hallway because six more patients are inbound, and we need to clear out our trauma-bays. Request sitter/family member to bedside Scenario 2 Electrolyte Imbalance, Risk for True Notify doctor Vital signs taken by automatic B/P Cuff q 15 minutes Stoma Status: Pink-Red/Moist Dusky Retracted Excessive bulging After leaving the room the provider tells the nurse that he hopes that he scared him into compliance with the treatment options. 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. He has a 20-year one pack history of smoking. Ineffective Self-Health Management True Read PT report Continent: Yes No Occasional Incontinence Frequent Incontinence Brief Safety Psychological Needs Increased acuity Offer assistance Skin warm and dry, all vital signs in WNL He asks to speak to a clergy member. Activity as tolerated with assistance. Senario 2 Vital assessment Perform pain reassessment Administer antipyretic medication Heterotrophs include (1) autotrophs, saprophytes, and herbivores (2) omnivores, carnivores, and autotrophs (3) saprophytes, herbivores, and carnivores (4) herbivores, autotrophs, and omnivores. Fall, risk for True -Complete secondary assessment once the patient is in bed focusing on complaint of pain resulting from the fall Vital Assessment Neuro WNL alert and cooperative. Fall, risk for: True Notify family as to when they may come and visit. Allow for non-compliance of request -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 Scenario 5 -Explain to patient why his throat may be sore Fall Risk Increased acuity -Remove the dinner tray and make sure the diet is soft food. -Check on patient/sitter hourly Sexuality: True. Physiological Wound site clean, dry and intact NPO, NG-tube to low continuous suction. The oncologist is recommending Docetaxel as opposed to an orchiectomy. You are told that he has intermittent chest pain with substernal burning that radiates to his mid-back. Explain reason for assessment and procedure He warns the patient that if he does not comply with the treatment and preventive measures, he will need other treatments that may include. Palliative care. Combien gagne t il d argent ? Deficient Knowledge False Full assessment Chronic Pain True No NPO with small amount of ice chips only. His left humerus is fractured and splinted. There is an initial triage provider written set of orders at her bedside for a STAT Chest X-ray, IV with NS, O2 NC, and STAT CBC and Chemistry. You enter patient's room. Yes 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.) . Infection, Risk for True Fall, risk for: True No Known allergies (NKA). Self-Care Deficit: True No known allergies. Offer masks to visitors Mr. Greer has just returned from surgery. No response = 1, Range of Motion: Full, Limited You take his vital signs which are: Temp 101.3, Pulse 88, Resp 24, B/P 116/84. Ruth Cummings Trustee Vice Chair Audit Chair . Dr. Levine, Marcella Como, 38 yr-old, Sexual Trauma Victim (Rape), unknown assailant. Assist patient out of bed Scenario 4 The nest morning the gastroenterologist informs Mr. Gonzalez that his EGD confirmed a diagnosis of Barrett's esophagus with Dysplasia. Notify doctor Paul Greer No Known allergies (NKA). Upon entering room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." . August 13, 2020 // by Angela McGowan. Observe closely first hour Full assessment of patient. Senario 3 All opinions are mine alone. Verify call light/bed safety precautions 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. Scenario 1 Notify Physical Therapy (PT) Reasses temp in 1 hour. Imbalanced Fluid Volume, Risk for True Background Robert Sturgess the client was admitted with Metastatic cancer of Colon, with history of diabetes. 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. Peripheral Neurovascular Dysfunction False Notify lead nurse/doctor The cycle of freezing and thawing damages the abnormal cells. Your notice Mr. Thomason is lying supine, appears slightly cyanotic in his lips, is exhibiting more effort to breathe, and is increasingly restless. Visual assess LOC Normal acuity Apical Pulse Rate: Heart Sounds: Normal S 1 S 2 S 3 Scenario 2 Therapeutic communicationT Use therapeutic communication/Active Listening Gastrointestinal Assessment -Reorient Patient to person, place, & time Use therapeutic communication/Active Listening Dyspnea at rest Dyspnea with minimal activity Use of accessory muscles Blood, Glucose 185, 4 units of insulin sliding scale for coverage. Pupils PERRLA, eyes clear. You enter his room and recognize that Mr. Thomason appears to be talking to himself and appears confused. Today's incentive spirometry Tidal Volume is 1250ml, improvement over yesterday's 900ml. Increased fall risk. Dr. Starks, Physiological Report current urinary output quantify per hour and color of urine Esteem Document results and findings Awaiting transport. Assess for bowel sounds Offer bedpan His difficulty voiding finally motivated him to seek care. Radiofrequency ablation, which uses heat to remove abnormal esophagus tissue. Neuro WNL alert and cooperative. Assign nursing diagnosis and plan the appropriate intervention and evaluate outcomes while working through time pressure and distractions, including random call light requests. Swift River Medical-Surgical. Neuro WNL's, alert and cooperative. Mr. Thomason appears now better oriented and MD arrives unexpectedly to examine him. Senario 5 Mr. Sturgess is uncomfortable with experiencing urinary frequency that keeps him from resting. Obtain and provide the infectious disease doctor's contact information for him. She is having some difficulty breathing. Respiratory Rhythm: Regular Rhythmic Irregular Periods of Apnea Cheyne-Stokes Vital assessment Fall Risk Increased acuity Acute Confusion: True Rapid Response team arrived including anesthesia. Remain with patient Notify Doctor for pain medz Scenario 1 No known allergies (NKA). Disturbed body False Mr. Gonzalez's repeat troponin was negative and no significant elevation in his other enzymes. Scenario 4 Compromised Family Coping False Toggle navigation Swift River. Perform circulatory evaluation Scenario 3 Recently he manifested an unusual black lesion on his thigh and developed an opportunistic fungal mouth infection which was treated successfully. Nausea: False Constipation, Risk for True 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) Awaiting diagnostic labs. Glasgow Coma Scale 0-15 Musculoskeletal Ms. Getts is requesting water to drink. Impaired Skin Integrity, Risk for False Palliative care. Notify lead nurse/doctor Aggravating Factors: Elevate head of bed Strict I&O and strain all urine, filters in bathroom. Nausea: False Notify doctor Vital re-assessment -Ensure patients is positioned in bed properly He is experiencing new onset of shortness of breath and has a nasal cannula with 2L of Oxygen in place. Readiness for Self-Care Enhancement True Bowel sounds: Active, Hyperactive, Hypoactive, Absent (listen for full 5 minutes) Provide emotional support. Provide comfort in pre-surgical room Mr. Dominec.