20ga. Upon entering the room, you find Ms. Rails sleeping. Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. The patient has a Foley catheter in place and is reporting 8/10 incisional pain and he is asking why his throat is sore. Fall Risk Increased acuity Assume role in response team of documenter -Reinforce to the patient to not get out of bed 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. Provide comfort and pain measures Scenario 5 She has arrived in pre-op and about to have surgery this morning. Document results palliative care. Anxiety True Mr. Greer has just returned from surgery. Fall, Risk for True Discharge instructions Stools are decreasing but patient remains very weak. Now, third day post-op, Mrs. Stukes appears sad and depressed upon entering the room. -Remove the dinner tray and make sure the diet is soft food. -Provide a diversional activity to pass the time while waiting on the HCP and inform wife that the HCP will be coming soon Scenario 1 Wash hands 20ga. Vital Signs: B: 160/92, P: 96, R: 22, SpO2: 98, T: 98.9F, 37.1C. Wash and glove hands Kathy Gestalt, 33yr-old, Dx- second day post-op open right Tibia/Fibula fracture, plaster cast in place on right lower leg. Acute Confusion False Electrolyte Imbalance False Assess for bowel sounds Include patient condition change in shift report sounds= 2 Senario 2 Psychological Needs Normal acuity Radiofrequency ablation, which uses heat to remove abnormal esophagus tissue. His children are visiting, and they are very supportive. Your Swift River Virtual Clinicals account has been linked to your ATI Student account. Provide for physical and thermal comfort. Scenario 4 Use therapeutic communication/Active Listening Hypothermia False Bladder distention Pelvic pain Low back/flank pain 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. -Assess the patient's anxiety level while using therapeutic communication to decrease patients' stress. She has just been transported from recovery. Fear True Refer call to contact health department Eclectic Recipes Fast And Easy Family Dinner Recipes Skin integrity, impaired True Gait: ______________________________, Skin Integrity Assessment I need to be reporting!" After 3 hours, Ms. Monson is now crying asking to be released from these restraints and for someone to take her home! Allow for non-compliance of request Activity as tolerated with assistance. -Explain to the patient that he has a procedure, and he cannot eat. Call Rapid Response protocol initiated -Perform neuro assess No weight bearing today. Your response to all of them would be: Scenario 1 Med Surg - Swift River_2020 | NURS 320 Med_Surg_Swift_River_Graded A Dr. Sangerstien, Viola Cumble, 92yr-old, second day post-op hip repair, Allergic to Penicillin. Safety -Evaluate patient's understanding of teaching Educate patient A special lowbed has been ordered that will lower to the ground. Arthur Thomason Impaired skin integrity: False, Anxiety: True Scenario 2 Blood-tinged mucous, productive cough. Fall Risk Increased acuity Scenario 2 Ronald Burgundy Carotid:____ + Bilateral Other: _____________ RUE: Non-pitting Pitting ___+ All opinions are mine alone. Assess intake and output and possible reasoning Neuro WNL, alert, and cooperative. Scenario 2 Home; Our Focus; Our Legacy; Our Partners; Our People; Our Fellows; Our Investments She is with her physician. Noncompliance False Therapeutic communication. Nursing questions and answers. Sensorium Increased acuit, Physiological Shock False Scenario 3 Ineffective Self-Health Management False Excess Fluid Volume, Risk for False Her pitcher has already been filled three times this shift. Assess for bowel sounds Oriented to: Person Place Time Vital sign Temp 98.4, BP 136/78, P 72, RR 20, SaO2 97%. The tour started nicely through the new area Hafencity but then continued to the area under development and a very desolate district of Hamburg. -Ask the patient if it is okay to discuss his care in front of his children. Mr. Mancia is non-English speaking patient and is fearful of being discovered as an illegal immigrant. Notify doctor Knowledge Deficit True Swallowing: Intact Dysphagia Aspiration Precautions -Explain to patient why his throat may be sore -Draw a repeat CBC per HCP order to determine current Hemoglobin status Pain Level Increased acuity He has not had his BP medication today. Nr 325 final exam quizlet chamberlain - gqqa.wikinger-turnier.de You enter his room and recognize that Mr. Thomason appears to be talking to himself and appears confused. Hopelessness True Fear True He is restless with slight confusion but is easily orientated with attempts from nurse. Assign nursing diagnosis and plan the appropriate intervention and evaluate outcomes while working through time pressure and distractions, including random call light requests. Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. Impaired Mobility True Sleep deprivation 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. Course Hero is not sponsored or endorsed by any college or university. Awaiting diagnostic labs. Review pain medication order Nathaniel Gonzalez Scenario 2 Impaired Skin Integrity, Risk for True Oral Care This information is HIPAA protected and you cannot share anything with them. Dr. Brown, Educational Needs Increased acuity Scenario 1 and the GI cocktail given in the ER did relieve his CP but not completely. Evaluation patient after consult He states, "This is not serious." Scenario 3 Infection, Risk for True Assess toe movement and capillary refilling Mrs. Pittmon states she has had numbness for years but "now I can't . Inappropriate words = 3 Acute Pain False Scenario 5 -Start an IV Notify doctor Apply oxygen Compromised Family Coping False Shock, Risk for: False Skin: Warm/dry Clammy/diaphoretic Skin Turgor: Brisk Tenting The nurse identifies self to the nurse triaging patients and is directed to trauma room 4. Scenario 2 Neuro WNL, alert, and cooperative but worried about scarring and is reluctance regarding walking on leg. -Tell the wife that you will speak to the husband, and this is apprehension is expected with this surgery/diagnosis. You arrive in room to find Ms. Monson talking to herself. Seek clarification He also has a history of hypertension and takes Tenormin (Atenolol) and Atorvastatin (Lipitor). Scenario 1 Connect telemetry Evaluate outcome of dietary plan Explain that he will probably not be going home at least until his doctor sees him. -Set-up for stat portable chest x-ray Imbalanced Nutrition False Ineffective Peripheral Tissue Perfusion False Verify call light/ bed safety precautions Tear, Ecchymosis, Contusions, Bruising Neuro WNL alert and cooperative. Health Change Increased acuity Robert Sturgess Scenarios Swift River.docx - Course Hero Scenario 1 Psychological Needs Increased acuity Remain with patient Other: _______________________________ 156 terms. The lesion was identified as Kaposi's Sarcoma. Nutrition True Scenario 2 Scenario 5 Ms. Cumble states that she has not had a BM for three days. Need frequent reminder to stay in room and maintain mask precautions. Nausea False Scenario 2 Regardez le Salaire Mensuel de Ubah Kalimat Efektif Online en temps rel. Observe closely first hour Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. Scenario 4 RS Flashcards | Quizlet Deficient Fluid Volume False Deficient Knowledge False Clinical 2. Report this activity immediately to the hospital privacy officer -Complete neuro checks as ordered Skin warm dry, bruises on forehead with small laceration. Senario 3 References; Access My Virtual Clinicals; Medical-Surgical. He is complaining of pain in his left arm, and pain in his left chest when he tries to take a deep breath. Provide information for MD to call family at home and explain what has just happened Scenario 1 Vital assessment Scenario 4 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. Document results and findings **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 (for older swift river patients see other pdf files loaded at the bottom of this file) Preston Wright Room . Safety- Vital signs -Temp 98.2, BP 94/60, P72, RR 22, SaO2 99%. Senario 5 Chronic Sorrow False Blood Glucose 185, 4 units of insulin sliding scale for coverage. Nutritional Intake: Adequate Inadequate BMI: Ambulates with minimal assistance. IV maintenance fluids with D5 1/2 NS with 20 KCL @ 125ml/hr in left forearm. 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. Skin integrity at risk True Elevate Extremity Allow husband to come into recovery for a quick one-minute visit. No response = 1, Mobility: Pain Level Increased acuity You escort them with you to the ICU. DSD (dry sterile dressing), forehead laceration clean and dry intact. Acquire daily weight and food intake His past symptoms for three months have been that he noticed a slight hoarseness in speaking, a slight dry cough not related to a cold, and upon examination had a "pea-size lump on the center of his neck". Scenario 2 Bleeding, Risk for True No Constipation, risk for: True Skin moist, respiratory bilateral wheezes and rhonchi. Combien gagne t il d argent ? Verify Call Light/Bed Safety precautions Bleeding: True Noncompliance True Esteem Palliative care. ExplanationAnxiety/ fear True Skin cool to touch and appears pale. Ask patient to explain to you what procedure she was expecting to have this morning. 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. 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. Scenario 5 ASA is held but morphine 4 mg was given after his GI cocktail. Fall, risk for: True -Check on patient/sitter hourly Decreased Cardiac/perfusion False Cardiovascular Assessment -Explain to Mr. Burgundy that space in the ED is allocated based off of patient need Educate patient regarding patient care Reapply restraints 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 Offer nutrition/toilet She has IV access and has received a small dose of Valium to reduce apprehension. Remind physician to wash his hands before examining the patient Scenario 4 She is also investigating bone marrow transplantation. Robert Sturgess Scenario 1 Mr. Sturgess is recently diagnosed with metastatic cancer of colon and he and his family have chosen only palliative care. Reassure patient and help explain any new orders from physician to patient Document Procedure Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma. Recently he manifested an unusual black lesion on his thigh and developed an opportunistic fungal mouth infection which was treated successfully. Health Change Increased acuity Document results/findings Evaluate/Modify Mobility Plan, Carlos Mancia, 48yr-old, Spanish speaking migrant worker with no known past medical Hx. Solved nursing care plan for Linda Pittmon, a 74 -year old - Chegg Document results Social worker with patient this morning. Safety- Acute Pain True Two hours later, Mr. Duncan is asked how frequent his stools have been today. Imbalance nutrition: True Increased fall risk. Strict I&O, regular diet, intake 50%. No Known allergies (NKA). Scenario 5 Scenario 4 He has a 20-year one pack history of smoking. This shop has been compensated by Inmar Intelligence and its advertiser. -Medicate for pain Needs frequent reminding due to determination to do things herself without assistance. -Explain that Radium-223 mimics calcium and is absorbed during new bone growth. Wash and glove hands Scenario 5 Educate patient Scenario 4 Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. Request time she can arrive and staff to help with transfer Combien gagne t il d argent ? Incomprehensible 3Check surgical consent for correct procedure and make sure operative site is marked. Swift River Med Surg Scenarios Answers - Homework Score