Document pt's statements. Palliative care. Deficient Knowledge False Physiological- Reapply restraints Document Procedure Scenario 1 Sleep Deprivation False Vital re-assessment Recent chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes. The patient got dizzy when he stood up from the commode. Powerlessness True. -Tell the wife that you will speak to the husband, and this is apprehension is expected with this surgery/diagnosis. Anxiety True Ms. Getts is being transferred as an emergency to Critical Care. Type of Line: Peripheral, location ______________ CVL, location _____________ PICC, location _______________ Grieving: False Respirations -Continue to observe urine for hematuria and document findings Contact Social Services Impaired Home Maintenance management r/t client or family False Senario 1 While assessing the patient, Mr. Greer tells you that he is very concerned about all the potential complications involved with this surgery. Scenario 2 Pain Level: Increased acuity Mrs. Smith shares with you that even though she signed the operative consent she was not sure if this was the right surgical procedure for her. Skin Color: Consistent with ethnicity pinkish-tan light-tan dark-tan light-brown dark-brown Comfort/Pain Assessment Encourage Mr. Dominec to discuss with his partner his best treatment options. Acute Confusion: True Stoma: N/A Colostomy Ileostomy Effluent Consistency: Ann Rails Mr. Mancia's vital signs upon assessment are Temp 101.2, P 94, RR 20, BP 122/82, SaO2-91%. -Reassess patient Educate patient Scenario 2 Safety -Ask Mr. Burgundy to lower his tone as it can be disturbing to other patients Scenario 4 Full assessment He tells the nurse he has called his wife and wants to be discharged now. Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma. -Contact HCP to determine when they are available to speak with the patient Document results and findings Senario 2 Reassure patient of options Therapeutic Communication Decisional Conflict False Impaired mobility: False Scenario 4 Pain Level Increased acuity Notify doctor Release restraints/full range of motion ASA is held but morphine 4 mg was given after his GI cocktail. Begin post op education for day one Senario 3 You explain that he is receiving a higher level of care and was he was sedated before leaving the floor to make him more comfortable. Fall, Risk for True Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. Regardez le Salaire Mensuel de Tthuchicago Org en temps rel. But that's changing. John Duncan -Discuss with family sitter if there are any other family members who can help with monitoring Lithia Love and belonging IV fluids of D5 1/2 NS are infusing at 100 mL/hour to his right forearm. Esteem Scenario 2 Now, meeting the CDC definition, he has full blown AIDS but is asymptomatic at this time. Neuro WNL alert and cooperative. Acute pain: True 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? -Ensure patient privacy and call for help and assist patient to bed once help arrives 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. Check PRN pain order -Take initial vital signs (room air Pulse Ox) Senario 1 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! No Known allergies (NKA). Sensorium Normal acuity, Physiological Safety Nausea False Mrs. Pittmon states she has had numbness for years but "now I can't . Neuro WNL. -Check patency of Foley catheter, urine color, and ensure it is secure to the patient's leg Ineffective Self-Health Management False Neuro WNL, alert, and cooperative but worried about scarring and is reluctance regarding walking on leg. Scenario 4 Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Disoriented, confused = 4 Safety- Wash and glove hands Her husband who is present states, "I thought it was just a lumpectomy she was having this morning." 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 Document and provide copy for Mr. Dominec to share with his follow up appointment tomorrow. Psychological Needs Normal acuity Scenario #3. After two hours, Mr. Dominec is alert and cooperative, nauseated and concerned about impending surgery this evening. Scenario 5 In reassessing Ms. Monson, her vital signs are: BP -106/82, Temp-98.2, P-106, RR-18, SaO2-88. Bleeding, Risk for False Ramona Stukes, 69 yr-old, third day post-op cholecystectomy. -Instruct Mr. Burgundy and his cameraman to stop immediately Temperature is now 102.8. Fear True Your notice Mr. Thomason is lying supine, appears slightly cyanotic in his lips, is exhibiting more effort to breathe, and is increasingly restless. : 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. Patient, and family upset regarding dx. Self-Care Deficit: True Yes Productive Non-productive Describe Sputum: _______________________ RLQ: RUQ: LUQ: LLQ: Acute Pain True Impaired Home Maintenance Management r/t Client or Family False Scenario 3 Severe pain (10/10) medicated q 30 minutes x4 with IV Morphine 2mg with little relief. -Begin q15 minute neuro checks Needs frequent reminding due to determination to do things herself without assistance. He has been taking his HIV medication daily. Mr. Greer is on the floor still but is awake and oriented and is complaining of back pain below his right scapula. Upon entering room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." . The cycle of freezing and thawing damages the abnormal cells. Full assessment Report this activity immediately to the hospital privacy officer Other: _______________________________ Why is cysteine such an important amino acid for defining the tertiary structure of some proteins? Gait: ______________________________, Skin Integrity Assessment He is aware that he may not have an erection and may need depends for bladder incontinence. Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. Robert Strurgess Pain Level Increased acuity Administer antipyretic medication His original lymph node biopsy was negative. Verify call Light/bed safety precautions Safety 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. Bowel Movement Total: x________________, Hygiene Times c/o headache- medicated with Lortab 5mg PO at 0900, takes Lomotil 10ml PRN q 4 hours last dose at 0834. LOC Normal acuity Observe closely first hour When she moves him to the hallway, Mr. Burgundy begins yelling at you "Do you know who I am, I demand a room! Notify family as to when they may come and visit. Continue.Robert Sturgess Room 305 Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. If patient statement differs from the surgical consent she has signed, notify surgeon immediately The impedance per phase in the load ist 14+j1214+j 12 \Omega14+j12. Pain and numbness in legs for one week. The patient tells the nurse that yesterday he was, "concerned about having an erection, and now they want to cut off my testicels". Scenario 3 Infection, Risk for True Hopelessness False. 2. In the interim, start an IV and start infusing Ringers Lactate. Impaired Skin Integrity False Administer antipyretic medication Apply nasal cannula Seek clarification Excess Fluid Volume, Risk for False Safety- Health Change Increased acuity Deficient Fluid Volume True Genitourinary Assessment Description: Sharp Stabbing Throbbing Aching Cramping Other: -Explain to Mr. Burgundy that space in the ED is allocated based off of patient need Ineffective Airway Clearance True The provider explains that it is a pre-cancerous stage in where the cell develops abnormal features. He is pale, weak, diaphoretic, and appears anxious. Home; Our Focus; Our Legacy; Our Partners; Our People; Our Fellows; Our Investments Dr. Rondeau, Educational Needs Increased acuity Disoriented to time and place, speech slurred. Therapeutic communicationT Health Change Increased acuity Ruth Cummings Trustee Vice Chair Audit Chair . No known allergies (NKA). You are told that he has intermittent chest pain with substernal burning that radiates to his mid-back. except 115 pulse, which is normal for him. Obtain urinary screen You question her while reviewing her operative consent and determine that everything is correct. -Assess patient LOC, by walking patient and asking them to take deep breaths. Scenario 5 Health Change Increased acuity Hx of dementia, from nursing home, fall one day ago. Report and document results Non-significant past medical Hx. Combien gagne t il d argent ? Report to charge nurse/ head nurse the need for staff education. Rapid Response team arrived including anesthesia. Notify doctor Vital assessment Scenario 5 Expresses fatigue, fear, concern, and desire for recovery. Evaluate understanding The client is onDemerol 25mgSlow Intravenous Push (SIVP) for pain. Physiological- The Swift River is one of the most unique and popular trout fishing destinations in Massachusetts, yet the dynamics of this exceptional fishery have not been well understood. Dr. Starks, Physiological -Call security for assistance and compliance officer The nest morning the gastroenterologist informs Mr. Gonzalez that his EGD confirmed a diagnosis of Barrett's esophagus with Dysplasia. You are about to call the Surgical ICU and give report. The emergency bathroom light goes off and the nurse finds Mr. Greer on the floor in the bathroom. Skin integrity at risk True Scenario 2 Scenario 5 He chooses to go home and see the doctor tomorrow in his office. Safety Sa fortune s lve 2 000,00 euros mensuels Inspect cast site How was this -Evaluate patient's understanding of teaching -Document and contact nursing supervisor/Charge nurse You arrive in room to find Ms. Monson talking to herself. Educate pt regarding changes to POC Anxiety True Full head to toe neuro assessment. Scenario 3 Perform pain reassessment Scenario 2 Scenario 2 Arthur Thomason It is determined that Mr. Sturgess could achieve better pain control w/ a PCA pump Inform his partner that everything is being done to keep him comfortable. Senario 3 is a 57 y/o who has been admitted for a radical prostatectomy. Assess Dr. Altace, Educational Needs Increased acuity -Complete incident report. Scenario 5 Elevate head of bed However, these abnormal cells do not have the capability to spread to other parts of the body. Impaired Home Maintenance Management False What is the ratio of Fe\mathrm{Fe}Fe (II) atoms to Fe(III) atoms in this compound? jasmine . Chronic Pain False Background Robert Sturgess the client was admitted with Metastatic cancer of Colon, with history of diabetes. Ronald Burgundy Scenario 3 Assume role in response team of documenter Decreased cardio tissue perfusion: False Kathy Gestalt Attempt to orient to person, place, and time Explain that he will probably not be going home at least until his doctor sees him. Scenario 1 Scenario 2 Leave to break room and not continue in conversation. Scenario 4 Bleeding Risk for: False Wash and glove hands Physical Mobility, Impaired True Anxiety False Disturbed Sensory Perception False Disturbed Body True -Check on patient/sitter hourly No response = 1, Range of Motion: Full, Limited Robert Sturgess Robert Sturgess 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. Scenario 5 Read PT report Fall Risk Increased acuity Deficient Knowledge True Roger Clinton, 57-year-old male construction worker arrives at 0600 to be prepared for a partial thyroidectomy to determine if he has cancer. Senario 5 Filmotka filmu Najvyia ponuka (2013). BP 154/89, P 94 F, R 22, T 98.3F, SaO2 95% on room air. Vital Signs: B: 160/92, P: 96, R: 22, SpO2: 98, T: 98.9F, 37.1C. Evaluate/modify plan of care Fall, Risk for True Full assessment 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. -Reassess patient's physical status prior to leaving him in the hallway Stools are decreasing but patient remains very weak. Use therapeutic communication/Active Listening -Perform admission assessment Replace oxygen nasal cannula that had become disconnected A few hours after speaking with the sitter about the patient needing complete observation, you notice the sitter outside of the room talking on the phone. Non-significant past medical history. Scenario 1 Scenario 4 -Reinforce to the patient to not get out of bed -Advise patient not to get up and walk on his own Chronic Sorrow False Then the bus splashed into the river for a cruise. Fall, Risk for True Place call light and check bed for safety Ms. Rails was medicated with hydrocodone 5 mg PO two hours ago and is now complaining of pain (8/10 pain scale). Offer assistance in providing more information about treatment options for newly diagnosed AIDS patients. Neuro WNL alert and cooperative. She has arrived in pre-op and about to have surgery this morning. -Offer nutrition and/ or toileting Notify Doctor for pain medz Scenario 4 Urinary Catheter: N/A Indwelling Short-term Indwelling Long-term Date of Insertion:________ Size: _____F He is having some difficulty hearing and complains of ringing in his ears. Safety Offer nutrition and/ or toileting He requests no visitors at this time, but later asks for his family to be called to discuss a plan of care. Call rapid response Upon assessment, you determined that she is confused to person, time, and place but is easily directable. -Reapply the NC that he was admitted with at 2L Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma. You return to the break room on your floor. Notify housekeeping. Incomprehensible Ambulates with assistance. -Inform Mr. Burgundy that he cannot report from the ED, as patient privacy is strictly protected by HIPPA , queen speech jaguar factory 1956 transcript,

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