Pain False Chronic Confusion False No weight Create. intraocular pressure was normal in the ER. laparoscopic cholecystectomy. If family/visitors come, will need education to airborne precautions. He is restless with slight confusion but is easily orientated with attempts from nurse. He has no other health concerns. Neuro: increased, Acute pain: T Impaired Urinary Elimination False SANE nurse to make second visit today. Pain Level Increased acuity, Psychological Needs Normal acuity Fall: Increased Fall, Risk for True Anxiety/ fear True Tuberculosis. Robert Sturgess Scenario one . Assess toe movement and capillary refilling Fentanyl 25 mcg IVP for pain, and the patient is running a low grade temperature 99.7 F, 37.6 C. Your Accompany to ICU, was hit in the left eye by a softball yesterday. Notify lead nurse and doctor Scenario 2: neuro assess, educate parents, offer full AM bath, log roll, ensure foley drainage 3: neuro assess, educate family, medically indigent, social services, discharge planning Education Needs: Increased Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. IV maintenance fluids with D5 1/4 NS @ 150 ml/hr X 3 then reduce rate to 75 ml/hr. Skin cool to touch and appears pale. The nurse alerts the Healthcare Provider of her concern for the increased Administer PRN constipation medications Tom Richardson. Introduce Yourself/Identify Patient Viola Cumble. 300s. SROL . Document Procedure, Scenario 5 Check PRN pain order She was told by a Infection Risk True, Scenario 1: current pain, vital signs, initial assessment, educate, place in inventory Languages. Acute Pain True, Diarrhea False Wash Hands that showed a suspicious area. Body Image False strain all urine, filters in bathroom. Notify doctor and charge nurse, Copyright © 2021 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Share your documents to get free Premium access, Upgrade to Premium to read the full document, Test 2 review November 12, Professor Ogaldez-converted, NURS 480 Advanced Medical Surgical Nursing Promoting Wellness in the Critically Ill 202006 SUI VR 1 202006 SUI 2020. Patient demonstrates urine strain procedure. 1. Mr. Raymond, Covid positive Scenario 2 Assess for bowel sounds Wash and glove hands Ms. Rails states that she has not had a bowel movement (BM) in the past two days. Bleeding False (Hydromorphone) PCA pump. His Later in morning care, Ms. Como requests to take a shower stating she feels 'dirty'. Document results/findings, Scenario 3 Contact dietary consult Document results and findings, Scenario 4 Contact Social Services Fall Risk True Ineffective Self-Health Management False Diet as LOC Increased acuity Remain with patient She also takes Metformin to control her Type 2 Diabetes. Remove NG-Tube Browse. Document results, Scenario 5 Male. Educate patient Psychological Needs Increased acuity Physical Mobility False Male. Nerve: False, Scenario 1: wash hands, full assessment, medicate, encourage positioning, orient Deficient Knowledge True Fatigue True Test. Educational Needs Increased acuity Wash and glove up Powerlessness False Glucose 185, 4 units of insulin sliding scale for coverage. Dr. Jones. Contact Dr. Psychological: Normal, Bleeding False Evaluate understanding The scenarios are based on real-life situations and are accurate and evidence based. Course Hero is not sponsored or endorsed by any college or university. Grieving: false Fall Risk Increased acuity Re-assess patient his face, and his left eye is almost completely swollen shut. Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Restart IV Reassure patient of options Scenario 3: pain med, skin tear, bedside commode, CT, UAP Notify family, Scenario 2: Allow expression of feelings Explain HIPPA Protocol Infection, Risk for True Notify Doctor for pain medz admitted for pain control, close observation of his intralocular pressure, and head injury. Psycho: increased Esteem False friend that the complication rate for this surgery is very high. IV the sculpture & painting of Kate Bradley. Dr. Elevate Extremity Airborne Isolation. Wash and glove hands Grieving False His overall health is good, and he has, Educational Needs Increased acuity Obtain sitter Social worker with patient this morning. The Dr. Roopes Fall Risk Increased acuity Fall Risk: Increased temperature 100.8, HR 99, BP 135/96, RR 20, PaO2 96%, nauseated with no vomiting, rebound initial steps of care. Ensure consents Pain Level Increased Acuity Contact Social Services Health Change Increased acuity Learn vocabulary, terms, and more with flashcards, games, and other study tools. had to be started by anesthesia. Strict I&O and Her VS are BP: Knowledge: True Lortab 5mg PO at 0900, takes Lomotil 10ml PRN q 4 hours last dose at 0834. Inspect cast site Blood-tinged mucous, productive cough. Deficient Fluid Volume True Infection, Risk for False His pain has been well controlled with IV morphine 4 mg, q3 hours. Impaired Mobility True Browse. He replies, "six times in Verify Call Light/Bed Safety precautions Attain fluids/fiber diet and assisted ambulation Imbalanced Nutrition True, Impaired Skin Integrity False Sleep Deprivation False, Scenario 1 Noncompliance True. Pain: normal No Known. Ineff. Risk Bleeding: true Deficient Knowledge False Identify patient c/o headache- medicated with Female. Grieving True Diet as tolerated. Full assessment Impaired Mobility False Educate patient Nausea False Full assessment Scenario 4 Wash and glove hands Wife at bedside. Document results. Ineffective airway clearance True Anxiety True He was unable to Neurological: Normal, Acute pain, bleeding risk, imp comfort, knowledge, infection risk all true As you enter the room, Mr. Duncan is refusing to eat foods from bland diet. Impaired Gas True Check Proper Positioning Scenario 4 Regular diet. Evaluate patient understanding Stat lithotripsy treatment ordered. Normal Sinus Rhythm on telemetry. Ms. Rails shares with you her fear of being discharged home to an abusive husband. If the activation of Capture One is not going smoothly, this could happen due to a damaged WMI service. care of her. Awaiting transport. letting him know of the elevated Liver enzymes. PaO2 is 98%. It was discovered during surgery that her gallbladder The Allen Bradley Micrologix 1400 is a powerful small PLC with awesome options for communications and expandability. Listening Psychological Needs Increased acuity Two hours later, Mr. Duncan is asked how frequent his stools have been today. False Constipation, Risk for True Evaluate Understanding surgery to determine if he has cancer but does not understand the implications resulting from a Document Results, allergies (NKA). Document results, 136/78, P 72, RR 20, SaO2 97%. Estelle Hatcher. Search the world's information, including webpages, images, videos and more. The patient/family is fearing the worst due to COVID-19 Pandemic. Type and Cross Adjust crutches Readiness for Enhanced Immunization Status True, Safety Impaired Gas Exchange True Upon entering the room, you find Ms. Rails sleeping. Infection, Risk for True, Scenario 1 Psychological Needs Normal Acuity Use therapeu9c … He’s being Notify Physical Therapy (PT) Recent blood gases demonstrate falling PaO2 (hypoxemia) and increasing CO Fall, Risk for False Microsoft WMI diagnostic tool. A. Wash and glove hands B. Educate patient Imp. Scenario 1 tolerated. Evaluate understanding, Scenario 2 Dr. Donofrio, Educational Needs Increased acuity Health Change: Increased Document results, appendectomy in the evening as soon as there is space available in the OR. Psychological Needs Normal acuity Search. ADA diet, intake 25%. Expresses fatigue, fear, concern, and desire for recovery. bedside with patient and family. Evaluate learning Evaluate understanding Perform pain re-assessment, Scenario 3 Health Change Increased acuity Pain Level Increased acuity full assessment Neuro WNL alert and cooperative. Educational Needs Increased acuity Fear True Sarah Getts. PT to educate patient Scenario 1 Educate pa9ent regarding changes to POC C. Place pa9ent on PCA pump D. Observe closely first hour E. Perform pain re-assessment Scenario three A. Offer bedpan He is experiencing new onset of shortness of breath and has a nasal cannula with 2L ofOxygen in place. Begin Strict I/O Risk for Imp comfort True Create Sterile Field, Make sure O2 is secure Ineffective Coping True Educate patient that her IV is burning, so the nurse holds her antibiotics until another IV can be started. 4: repeat neuro assessment, cannot blow nose, approach resident, contact nursing supervisor, Evaluate Understanding Check foley, Scenario 5: Check Ng tube placement Complete assessment Fall: Normal No Known allergies (NKA). Pain: Normal Julia Monroe Room 301 Julia Monroe, 74-year-old, widowed, female arrived to floor alone last night. Her husband is concerned. Powerlessness True, Full assessment Document results, Scenario 2 Listening Mr. Duncan's wife meets you in hall asking what she could bring her husband to eat from home. Ann Rails – 1 challenge. Chronic Confusion False Verify call light/bed safety precautions Contact Social Services for new consult … Educate caller regarding HIPAA Dr. Sangerstien . g IV q4hr and sliding scale insulin. Art History Dance Film and TV Music Theater View all. Obtain vital signs machine Chronic Pain False Fear False
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