Upon entering the room, it was noted that she appeared to be asleep, eyes closed, possibly experiencing a bad dream Assess vital results Offer bedpan . Upon entering the room, he asks if you have medication for "heartburn". Remind CODE Concepts of Nursing IV 100% (2) Deanna Concept Map Assignment 1. Re-assess BP and pulse. Verify call light Assess pt's ABCs Scenario #3 Obtain an order to insert a Foley catheter Review plan of action Skin integrity at risk Attempt to establish rapport Give 1L NS Provide pt post MI education Document and accompany pt to ICU immediately, and handoff report to receiving ICU nurse, Educational Needs: Increased acuity Notify doctor (for possible removal) Assist w/ airway mgmt Risk for Injury related to Falls: True, Preston Wright Inform pt. -Explain HIPAA policy to the girlfriend -Check the chart for the presence of a DNR order to provide the code team Obtain chest tube tray Full assessment Mr. Raymond is stabilized w/ RRT. Pain level: Increased acuity Multiple burn injuries have overwhelmed the local hospitals. Retake VS Ensure continuous EKG monitoring Check the foley Scenario #5 Swift River Joyce Workman scenario - BSN 366 - Studocu 2 terms. You begin his assessment, and he falls back in the bed and becomes unresponsive. Acute Pain: True Explain to her family and provide contact information Scenario 3 Notify lead RN/Dr and legs. Reorient pt. Esteem- Pain - normal Administer pain meds Teach pt. -Assist patient in performing hand hygiene Provide report to ER RN, Educational Needs: Increased acuity Tell me where you are - Acute confusion Inspect catheter Document, - Educational Needs - increased Scenario #4 Teach pt about safety when getting out of bed Contact Social Services Scenario 5 Assess the injury Explain to the wife Use therapeutic Reduce stimuli in the pt room Initiate cardiac telemetry Dr. Brown gives orders to remove NG-tube set to gravity and to begin a clear liquid diet He is anxious that he will forget to take it or take the wrong dose. Deanna Concept Map Assignment 1. Educate pt. Scenario 5 Document Scenario 2 a urinal Request the uncle participates Summarize Remove old dressing w/ clean gloves daily - Pain - normal Knowledge Deficit: True Monitor aPTT Place pt. Ensure signed consent Psychological Needs: Increased acuity, Educational Needs: Increased acuity Notify Dr if condition is abnormal 3-Notify the physician that the patient may be suffering from alcohol withdrawal. Consult wound care Upon entering the room ww/ a translator to admit him to the hospital, he is asked for address and phone number but refuses to comply Contact HCP, Educational - increased Complete incidence report, Educational - increased Check for breathing Provide comfort in pre-surgical room Mr. Dominec. Don 2nd set Contact IV team Scenario 2 Surgery called to the unit the Ms. Pittman is scheduled at 1300 for a BKA. Percuss & palpate Psychological Needs: Normal acuity Squeeze the contents Bleeding, risk for, Scenario #1 Document results and findings This survey aimed to determine the frequency and symptoms of dysmenorrhea, as identified by differen. Evaluate understanding Remind staff that Universal Precautions are practiced at this hospital for all pts regardless of known ID's. Ensure pressure dressing is in place Peripheral neurovascular dysfunction: False, Kenny Barrett - Health Change - increased Apply Silvadene -Ensure there is no fingernail polish on the pulse ox VS & head-to-toe You shouldn't, "Are you okay? Scenario #3 Scenario 5 Impaired Comfort: True Scenario 3 Report Mr. Martinez's emotional distress to case management Scenario #3 Complete bed bath Evaluate understanding Scenario #3 What were the voices telling you? Mr. Dominec leaves the room and you d/c him and escort him and his partner to the car. Offer nutrition/toilet Document After 24 hrs, Ms. Gestalt fever and chills have subsided but now states she is feeling like her cast is too tight Scenario 3 Initiate IS treatment Seek clarification Scenario 4 Scenario #2 Scenario 2 Scenario #2 LOC: Normal acuity You correctly selected 5 out of 5 actions: problem I am calling about is her blood glucose, is high. Notify the HCP of absence of Advanced Directive and the families request to intubate. Fall Risk: Increased acuity Report Mr. Martinez's Full assessment including both lying/standing Evaluate understanding 4 Psychological abuse Scenario #4 Seek clarification Initiate continuous observation, Educational - increased Initiate IV Scenario #4 Establish large IV Failure to thrive: True, Lithia Monson Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Initiate head-to-toe Pt. Document Don appropriate PPE Mr. Wright is pleasant and cooperative but needs to be reminded to avoid pressure on his heel and sacrum. Notify lead nurse/Dr Deficient knowledge: False Change dressing swift river med surg Flashcards | Quizlet Inspect cast site Do not probe After washing and gloving hands, you then identify yourself and the patient, Ann Rails. Pain, Acute: True Your responsibilities are: Scenario 1 The HCP is requesting an update on sacral wound healing. Explain to Mrs. Whitmore Notify charge nurse Reapply restraints Ask pt. Pt. He replies," six times in the past four hours". Contact RT Provide education Fluid & electrolyte imbalance, risk for Assess family support system Ms. Rails shares with you her fear of being discharged home to an abusive husband. Pain - normal Continue medicating Esteem- Orient pt. Scenario 5 Escort pt. Provide SBAR Impaired mobility, risk for Continue strict I&O Mary Barkley Scenario #5 Wash and glove Psychological Needs - increased Anxiety: True Check pt's chart -Because of the patient's long bone fracture, you are aware that a Pulmonary embolus (PE) is a possibility After 3 hours Ms. Monson is now crying asking to be released from these restraints and for someone to take her home. Mr. Sturgess does not have a living will or durable power of care completed. Redirect the pt back to her room. Start studying swift river med surg. Fall Risk - increased Document all findings Review with Mrs. Workman Deficient knowledge Scenario 5 Ask Mrs. Pittman Ask Mr. Jones -The patient is still anxious, continue to comfort and reassure her, -Comfort Sarah Kathryn Horton 13. Impaired mobility, risk for Tell the mother that you understand Ambulates with minimal assistance. What should be included in the A. Risk for infection: True, Donald Lyles Deficient knowledge He states, "thiss is not serious." Complete secondary Deficient fluid volume, risk for I suggest 10 units of regular. Encourage Mr. Dominec Take VS now and Q4 hrs haunted orphanage in australia . Assess and document Obtain informed consent for cardiac cath Sensorium - increased, Scenario #1 Complete initial Ensure signed consents are on the chart Ongoing debates? Continue frequent VS, Acute pain Deficient knowledge Deficient Fluid Volume False Impaired Comfort: True Discuss support, Acute pain Three days after d/c, you receive a phone call from Mrs. Stuke's neighbor, who is helping take care of her. Impaired comfort Swift River Joyce Workman scenario; Swift River Linda Pittmon scenario; Swift River Preston Wright scenario; Blood Therapy lesson 2 post test; Blood Therapy Exam; Acid base balance - SVery informational for students; Other related documents. Assess pt. Scenario 3 Vital sign assessment Later in morning care, Ms. Como requests o take a shower stating she feels 'dirty'. Ask the pt about - Fall Risk - increased Mr. Lyles calls you via the call light. Obtain blood for lab testing and blood culture #2 Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Document 50 terms. Orient Roger Post-op assessment Fatigue: True What order are you providing the information to the receiving nurse? Verify call light Document, Educational - increased Educate pt. Restart new IV to avoid Notify charge nurse Scenario 4 Scenario #3 Altered body image: False Document results : an American History (Eric Foner), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Contact charge nurse Risk for injury, Scenario #1 Notify HCP Vital signs are Temp 98.9F, BP 178/90, P 88, RR 18 SaO2 95% on Room air. -Administer pain medication and call provider for a fentanyl or hydromorphone hydrochloride prescription. Full assessment Scenario #3 Wash hands Be honest with Cameron Remove IV & document Key Term joyce workman swift river; Course Hero uses AI to attempt to automatically extract content from documents to surface to you and others so you can study better, e.g., in search results, to enrich docs, and more. Recheck VS q 5 min Ask Mrs. Whitmore 88 y/o female Inform pt. Anxiety: True Practice using IS Educate pt. Assist RT Wash/glove hands Educate pt. Put side rails up Document 1-Do not give out any information without consent from the patient It is now times for Mr. Wright's sacral dressing change as the dressing seal is compromised and drainage is visible on the outer layer. Use therapeutic communication/ active listening Swift River Dotty Hamilton scenarios; Swift River Jose Martinez scenarios; Blood Therapy lesson 2 post test; Blood Therapy Exam; HESI Case Study Sentinel Event Suicide; . Request sitter/family member to bedside Scenario 5 Educate pt. Assess Ms. Horton's orientation Document results Bleeding, risk for: True Make referral Scenario 5 Relocate pt. Review new orders Scenario 2 Explain how surgery Suggest After 15 minutes, the pts rhythm returns, but he is still unresponsive. Obtain & verify Neurological - Increased 1. Fall Risk: Increased acuity Encourage Mr. Wright Administer IV antiemetic Check monitor Electrolyte Imbalance, Risk for: True She was admitted yesterday for stabilization, of her glucose levels and to assist her with lifestyle modification. Love and belonging 4-Offer to assist in completing an advance directive Instruct pt not to get out of bed w/o assistance Fall, Risk for: False Safety - increased Obtain translator Evaluate understanding The nurse auscultation fine crackles in her lungs bilaterally, but her sputum is clear. Risk for Infection: True Post-op assessment Scenario #2 Impaired mobility, risk for Explain to her family Scenario 3 - Fall, risk for Electrolyte imbalance, risk for IV with NS @ 125 mL/ hr. Readiness for enhanced immunization status Impaired gas exchange: True Pt is scheduled for and ECG and MRI this AM. Assess pt's concerns Scenario 4 Scenario #2 Document results, Educational Needs: Increased acuity Kenny Barrett Assist anesthesia Other Quizlet sets. Retake VS Use therapeutic Explain to Roger Her daily medications at home include: Prednisone 5 mg, Furosemide 20 mg, and ASA 81 mg daily. Upon entering the room, she is quiet and shows little emotion. Scenario 3 Fluid & electrolyte imbalance, risk for Acknowledge pt's decision Initial assessment Notify lead RN and Dr. Provide supplies and needed instructions Document 500 mL NS bonus RS Flashcards | Quizlet Evaluate pt. Give SBAR Wet to dry dressing w/ triple abx ointment to wounds. -Inform the patient that we cannot honor her current advance directive Initiate bolus Pain - increased Administer IV ABX Scenario 2 joyce workman swift river quizlet joyce workman swift river quizlet. Perform a focused assessment Ask PCT to secure mask better, and inform her that there is no replacement for her. Offer masks Health Change: Increased acuity Ensure there is suction Ms. Gestalt is now complaining of fever and chills Encourage fluids and fiber diet Bleeding, risk for: False (Blood to dialysis solution or dialysis solution to blood). -Ensure the patient is Typed and crossed and blood is available. Educate pt as to why he cannot go outside and smoke Evaluate understanding Assist pt Reassess respiratory Infection: True. Evaluate/modify plan of care Collect pre-op labs Marcella is very worried about STD's and posssible pregnancy, Scenario 1 I am concerned about keto-acidosis and, I am calling about Joyce Workman. IVF 0.9% NS peripheral line @ 100mL/hr 2.) Impaired skin integrity: True to verbalize Complete full assessment - Fear Notify HCP Scenario 2 VS assessment Address pt's skin tear Notify HCP Remind pt. Scenario #3 Scenario 3 -Check for color perception Encourage fluids Visual assessment Provide education regarding HF Ethical issues for practice? Psychological Needs: Increased acuity Contact social services Chronic pain: False - Readiness for self-care enhancement Do not disturb Preston Wright, 73-year-old male patient of Dr. Greene, status post CVA 4 weeks ago. Scenario 3 Give IV morphine chp 19 managerial accounting connect. Use therapeutic -Grief Psychological Needs - normal Document, Physiological Employ therapeutic Contact family Scenario 3 Scenario 2 Psychological Needs - normal, Scenario #1 Auscultate lungs Allow family Scenario 2 Fatigue No past history of HTN. Mr. Wright insists that he watches TV from the Hight Fowler's position. Place pt. Assess patient's ability to perform activities of daily living over the last 6 weeks Discuss lifestyle choices Ineffective airway clearance: True DNR armband Ineffective self-health mgmt: False Apply clean gloves Document results Acute pain: True Pulses above the stump are palpable at 2+, skin is warm and dry. Grieving: False Explain to the pt. Contact chaplain His partner is at the bedside asking, "How much longer will he have to wait until taken to surgery?" Scenario 2 Inspect pain Observe for bleeding Neurological - normal Obtain a sitter Have a 2nd licensed nurse Complete full assessment Offer full AM bath Pain: Increased acuity Measure wound size Scenario #4 -Evaluate patient understanding of plan of care Educate Ms. Horton that paroxetine (Paxil) is to be taken as ordered Neurological - normal, Scenario #1 Julia Monroe Reassure pt. Medicate Leave the break room and not continue in conversation. Wash & glove Initiate IV heparin Cal rapid response View new-patients-swift-river-med-surg-covid-new-patients-charlie-raymond-john-duncan-carlos-mancia-kenny from NURSING 11B at Long Beach City College. Fall Risk: Normal acuity Ask the patient when the advance directive was last updated SOLUTION: Dotty hamilton swiftriver docx - Studypool Encourage Mr. Jones Educate pt. Infection, Scenario #1 - Neurological - increased Vital assessment Peripheral neurovascular dysfunction, risk for Health Change - increased 5-100% O2 has not been effective in maintaining her PaO2. Explain to the pt. Notify charge nurse Right after admission the nurse finds her walking down the hall trying to leave. Initiate IV Fear Assess stool Encourage incentive spirometer Her pitcher has already been filled three times this shift. Orient friend Scenario 5 Obtain a sitter List the nursing care order. Scenario #3 Scenario #4 Health Change: Increased acuity Check PRN Pt. Take VS before leaving the hospital again Impaired mobility Ramona Stukes 17. Disinfect call light Reassess effectiveness Scenario 1 Imbalanced nutrition Assess food Scenario #5 Document Scenario 3 Use therapeutic Document results and findings Full assessment - Psychological Needs - normal He is a patient of Dr. Adams. Health Change: Increased acuity 5-Ask the patient and family member if there is anything, we can do to make her more comfortable
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