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She is having some difficulty breathing. Filmotka filmu Najvyia ponuka (2013). Skin warm and dry, may sit up on edge of bed today. -Reinforce to the patient to not get out of bed Fear: True His children are visiting, and they are very supportive. Notify Physical Therapy (PT) Ms. Rails was medicated with hydrocodone 5 mg PO two hours ago and is now complaining of pain (8/10 pain scale). No response = 1, Muscle Strength: WNL, Flaccid, Contracted August 13, 2020 // by Angela McGowan. Provide comfort measures Provide information for MD to call family at home and explain what has just happened Breath Sounds: Clear bilaterally. Wash and glove hands Offer assistance Document Results, Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. He also states he is feeling weak. We have more than 20 years' experience in the industry providing a quality service to our clients We pride ourselves on our customer-orientated service and commitment to delivering high end quality goods within quick turnaround times. Senario 1 Social worker with patient this morning. Document results/findings Document results -Complete neuro checks as ordered Vital Assessment Apical Pulse Rate: Heart Sounds: Normal S 1 S 2 S 3 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. Pulse Ox: ___________ % on ____________FiO2; Room Air; Delivery Device Scenario 2 Cardiovascular has pacer with rate of 82bpm on demand. Scenario 1 No Known allergies (NKA). Check surgical consent for correct procedure and make sure operative site in marked. Scenario 1 Perform pain reassessment Notify lead nurse Impaired Gas Exchange False Release restraints/full range of motion Skin moist, respiratory bilateral wheezes and rhonchi. Use therapeutic communication/Active Listening Regardez le Salaire Mensuel de Ubah Kalimat Efektif Online en temps rel. Assess Determine from medical record if partner is aware of his recent AIDS diagnosis. Anxiety True Scenario 3 Safety Vital signs -Temp 98.6, BP 114/62, P 100, RR 20, SaO2 94%. -Reinforce the risk if patient has not been NPO and ask the patient when the last time they ate. Scenario 4 -If cardiac is suspected call the provider and the rapid response team. Scenario 2 -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. Report current urinary output quantify per hour and color of urine Constipation False He is currently febrile with temperature 100.8, HR 99, BP 135/96, RR 20, PaO2 96%, nauseated with no vomiting, rebound tenderness in right lower quadrant, has elevated WBC's and surgeon feels this will be uneventful even though he has just been diagnosed with AIDS this past week. Vital signs are to be taken BID, and it is now time. -Offer nutrition/toilet Localizes pain = 5 This will treat any cancer that may have metastasized to the bone. Your responsibilities are: Scenario 1 Robert Strurgess Gown and mask Sa fortune s lve 2 216,00 euros mensuels Visual assessment You observe Ms. Getts being assisted by another nurse who is being blatantly rude and disrespectful to her. The emergency bathroom light goes off and the nurse finds Mr. Greer on the floor in the bathroom. Two hours later, Mr. Duncan is asked how frequent his stools have been today. Vital signs -Temp 99.1, BP 124/62, P 77, RR 20, SaO2 91%. Sleep Deprivation False. Scenario #3. Discharge instructions Incomprehensible Hopelessness False. -Ensure bed is in lowest position, and rails are in place Present health assessment including B/P and LOC and dressing. Pain Level Increased acuity Skin warm and, dry, all vital signs in WNL except 115 pulse, which is normal for him. Scenario 2 Fall, Risk for True However, these abnormal cells do not have the capability to spread to other parts of the body. Allergic to sulfa drugs. Notify housekeeping. Document results. Amount: _______ But that's changing. Widespread Color Change: N/A pallor cyanosis jaundice erythema #ozerysnackingrounds I am so excited to be partnering with Ozery Family Bakery today. She is also investigating bone marrow transplantation. Strict I&O and strain all urine, filters in bathroom. Senario 2 Powerlessness True. Psychological Needs Normal acuity -Have patient remain in bed, head elevated 30 degrees Vital assessment Skin Integrity: Intact No, describe below, Location Type Size Wound bed Drainage Scenario 2 Combien gagne t il d argent ? Nutritional Intake: Adequate Inadequate BMI: Fall, Risk for True -Inform Mr. Burgundy that he cannot report from the ED, as patient privacy is strictly protected by HIPPA He warns the patient that if he does not comply with the treatment and preventive measures, he will need other treatments that may include. Ms. Getts is now complaining of sudden sharp, substernal chest pain, very short of breath and is profusely diaphoretic. Bleeding: True -Take initial vital signs (room air Pulse Ox) -Medicate for pain 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. Impaired Skin Integrity, Risk for True He is pale, weak, diaphoretic, and appears anxious. Fall, Risk for True IV Fluids: INT lock IV Fluids ______________@ _____________ mL/hr Date on tubing: Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Chronic Pain, Risk for constipation, impaired nutrition, anxie, 4 units on insulin sliding scale for coverage, Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), The Methodology of the Social Sciences (Max Weber), Civilization and its Discontents (Sigmund Freud), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Give Me Liberty! Due to this, the provider would like him to stay in the hospital for observation. The patient describes this pain as a heavy pressure with intermittent stabbing. After leaving the room the provider tells the nurse that he hopes that he scared him into compliance with the treatment options. The cells are allowed to warm up and then are frozen again. Safety- The oncologist is recommending Docetaxel as opposed to an orchiectomy. Scenario 4 Fatigue True Flexes abnormally = 3 Document results Our Swift River Simulations are designed to help students and practicing nurses master their skills of Prioritization, Delegation, and Sequential thinkingwithout the requirement of being onsiteor even having to download software. Remain with patient She has IV access and has received a small dose of Valium to reduce apprehension. Tubes: None Salem Sump Nasoduodenal PEG J-Tube pH: ______ Abdominal Pain: Non-tender Tender/Pain Describe: The surgeon has suggested Androgen-deprivation therapy (ADT) with surgical castration (orchiectomy). Educate caller regarding HIPAA Scenario 5 Sarah Getts Scenario 5 Sleep deprivation: False Contact head nurse or supervisor in the OR to evaluate new situation Vital signs -Temp 98.4, BP 116/76, P 96, RR 20, SaO2 99%. Purposive Communication Module 2, Chapter 1 - Summary Give Me Liberty! Assist patient RLQ: RUQ: LUQ: LLQ: Social Isolation, Risk for True -Explain procedure to the patient Temperature is now 102.8. 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. Pain: No Yes: Location: ______________________ Acute Chronic Constant Intermittent IV Assessment/ N/A Scenario 1 -Remove the dinner tray and make sure the diet is soft food. Place pt on PCA pump He chooses to go home and see the doctor tomorrow in his office. Senario 5 Document findings Respiratory Rhythm: Regular Rhythmic Irregular Periods of Apnea Cheyne-Stokes Scenario 1 His left humerus is fractured and splinted. He has not had his BP medication today. Ms. Rails states that she has not had a bowel movement (BM) in the past two days. Check monitor -Evaluate patient's understanding of teaching VS: BP 158/90, HR 89, R 18, T 97.8 F. -Reassure patient that he will be moved to a private room as soon as possible Mr. Dominec decides he does not want to see Infectious Disease doctor about his new cough. Stoma Status: Pink-Red/Moist Dusky Retracted Excessive bulging Perineal Care -Check on patient/sitter hourly His CP is 7/10 and his BP is 165/96, P 92, R 18, SaO2 98 on 2L NC. Deficient Diversional Activity False -Instruct Mr. Burgundy and his cameraman to stop immediately Compromised Family Coping False Impaired Mobility True -Complete incident report. Request sitter/family member to bedside 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. Scenario 1 Don Personal Protective Equipment Non-significant past medical history. 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Therapeutic communication The patient has been scheduled for an EGD today and has an order for Omeprazole (Prilosec) and Carafate (sucralfate). Skin warm and pale. You are now preparing for discharge, place steps in order: Senario 1 Dr. Altace, Physiological- How does the Med-surg simulator work? Reassure patient and help explain any new orders from physician to patient The patient is asking you where her son is, the last place she saw him was right before the explosion. Vital signs are: B/P 112/78, temp. In the interim, start an IV and start infusing Ringers Lactate. Scenario 5 Vital Signs: B: 160/92, P: 96, R: 22, SpO2: 98, T: 98.9F, 37.1C. Description: Sharp Stabbing Throbbing Aching Cramping Other: Observe closely first hour Mr. Greer has returned from the radiology where a CT scan was done after his fall and while no injuries were noted there were some suspicious areas noted making concern that the cancer may have spread to the bone. 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. -Determine when a hospital provided sitter will be necessary Course Hero is not sponsored or endorsed by any college or university. Love and belonging Contact charge nurse. 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. Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. IV maintenance fluids with D5 1/4 NS @ 150 ml/hr X 3 then reduce rate to 75 ml/hr. Neuro WNL alert and cooperative. Safety Scenario 5 You enter patient's room. Re-assess patient Deficient Knowledge True Dr. Altace, Educational Needs Increased acuity Skin warm and dry, daily dressing changes, T-tube without drainage. They were also concerned about the next patient going into that room and the use of the lavatory. Scenario 1 Safety Dr. Donofrio. Elevate head of bed No -Continue to observe urine for hematuria and document findings It is now the second day post op and he is given discharge information. No Known allergies (NKA). Temp -Check patency of Foley catheter, urine color, and ensure it is secure to the patient's leg D/C plan- decrease pain and restore normal gait. Ms. Rails shares with you her fear of being discharged home to an abusive husband. Scenario 2 Document conversation You also notice the patient is more difficult to orient. No known allergies (NKA). Disturbed Sensory Perception True 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. Senario 3 Notify doctor Provide comfort and pain measures Temperature is 98.3, HR is 87, RR is16, BP is 121/74, PaO2 is 98%. Assess vital results Auscultate peripheral pulses and ROM. The patient was placed on 2 L O2 NC, EKG monitoring to include a 12 lead, Pulse Oximeter. Use therapeutic communication/active listening Senario 4 Needs frequent reminding due to determination to do things herself without assistance. Psychological Needs Increased acuity 2. Bleeding Risk for: False RLE: ______________ LLE: ______________, Casts/Splits: ____________________________, Motor response Verbal command = 6 Sleep Deprivation False However, he quit three years ago when he remarried; he and his wife have a nine-month-old baby. Esteem He is aware that he may not have an erection and may need depends for bladder incontinence. Disoriented to time and place, speech slurred. Sa fortune s lve 1 900,00 euros mensuels Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. Full assessment The ER nurse reports that his cardiac enzymes were borderline, (Troponin?, CK/CKMB?) Senario 4 Explain to her family and provide contact information. -Remove the lunch tray and ensure pre-operative consent has been signed. The charge nurse tells you she will send someone to assist you, and to get out 2mg of Versed to have ready to sedate the patient at time of procedure. Shock False Identify patient Airborne Isolation. : beach pearl), in walking distance of the velgnne ferry stop, is considered the mother of all urban beach clubs. Allow husband to come into recovery for a quick one-minute visit. Pain, Acute True 00 Comments Please sign inor registerto post comments. Mr. Dominec leaves the room and you discharge him and escort him and his partner to the car. Ineffective Coping False Swallowing: Intact Dysphagia Aspiration Precautions 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. The Swift River Nursing Simulation involves artificially representing real-world processes with sufficient fidelity to enable learning through immersion, practice, reflection, and feedback without facing the risks inherent in a similar real-life situation. -Explain to Mr. Greer that it may take several days for healing, and he may have temporary incontinence, but it will resolve over time. Call rapid response Bleeding, Risk for False Acute Confusion True Peripheral Neurovascular Dysfunction False. Genitalia: WNL (skin intact, no lesions) Abnormalities Describe: __________________________ Sitting, BP 109/60, P 114, Standing the patient becomes very lightheaded and the nurse has them lay back down. -Ensure patients is positioned in bed properly Senario 3 Apply oxygen Love and Belonging Tom Richardson Perform circulatory evaluation Scenario 4 List the nursing care order. Activity as tolerated with assistance. Deficient knowledge: False -Tell the patient to call immediately if the chest pain gets worse or they become short of breath She has been admitted to the floor with complaints of numbness in her right foot and ankle. Senario 1 Offer nutrition and/ or toileting He is married, and his wife is requesting to stay at his side. Impaired Gas Exchange True Vital signs- Urostomy: N/A Urostomy/Ileal conduit You now arrive in the recovery unit one hour post-surgery and you are told that the surgery went well. Physiological- Inform and educate spouse of dietary orders Skin Color: Consistent with ethnicity pinkish-tan light-tan dark-tan light-brown dark-brown -When the HCP arrives, stay in the room to determine whether you can continue care with the patient Safety He does not have an IV nor is he on oxygen. Radiofrequency ablation may be recommended after endoscopic resection. Request time she can arrive and staff to help with transfer Safety Encourage fluids/fiber/ambulation Gait: ______________________________, Skin Integrity Assessment In reassessing Ms. Monson, her vital signs are: BP -106/82, Temp-98.2, P-106, RR-18, SaO2-88. Sensorium: Normal acuity, Bleeding, risk for: False Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. Now, meeting the CDC definition, he has full blown AIDS but is asymptomatic at this time. Scenario 4 -Use therapeutic communication/active listening Cryotherapy, which uses an endoscope to apply a cold liquid or gas to abnormal cells in the esophagus. Following isolation precautions, you notice several family members are by his bedside and none of them are wearing face masks as requested by sign on door. Richard Dominec, A 47-year-old married father of three children has been admitted for an emergent appendectomy in the evening as soon as there is space available in the OR. Acute Confusion: True Inappropriate words = 3 Comfort/Pain Assessment c/o headache- medicated with Lortab 5mg PO at 0900, takes Lomotil 10ml PRN q 4 hours last dose at 0834. Allow for non-compliance of request Scenario 2 Dr. Anderson, Educational Needs Increased acuity He is complaining of pain in his left arm, and pain in his left chest when he tries to take a deep breath. Scenario 3 Chronic pain: True Mr. Greer has just returned from surgery. Strict I&O, regular diet, intake 50%. An abc-phase-sequence three-phase balanced wye-connected source supplies power to a balanced wye-connected load. Nausea/Vomiting: Yes No The patient is being prepared for discharge and his IV has been removed. Other: _______________________________ Impaired Skin Integrity, Risk for False Neptune is an average distance of 4.5109km4.5 \times 10^{9} \mathrm{km}4.5109km from the Sun. Remain with patient Perform full assessment and provide anti-nausea medicine. Fall, risk for True 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. RLE: ______________ LLE: _____________ The lesion was identified as Kaposi's Sarcoma. Pain Level Increased acuity Notify Doctor for pain medz -Start IV Safety Increased acuity, Physiological Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma. His overall health is good, and he has known he has been HIV positive for the past five years. NKDA Assessment The client vital signs are: Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%, Neuro WNL alert and cooperative. The nest morning the gastroenterologist informs Mr. Gonzalez that his EGD confirmed a diagnosis of Barrett's esophagus with Dysplasia. Notify doctor Scenario 1 palliative care. -Ensure patient privacy and call for help and assist patient to bed once help arrives You return to the break room on your floor. Check PRN pain order Gastrointestinal Assessment Safety He is emotionally distraught and is insisting that he be allowed to report what is going on from the ER. 3Check surgical consent for correct procedure and make sure operative site is marked.