-Medicate for pain Cross), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Principles of Environmental Science (William P. 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Course Hero is not sponsored or endorsed by any college or university. 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. Safety Wash and glove hands Skin warm and, dry, all vital signs in WNL except 115 pulse, which is normal for him. Hep-Lock in place left AC. Provide emesis basin/cloth LUE: Non-pitting Pitting ___+ Neuro WNL. John Duncan Inform and educate spouse of dietary orders Date of insertion: _________________________ Date of dressing: _________________________________ Assessment of bowel movement Skin integrity at risk True If the source voltage for the a phase is Van=12080V\mathbf{V}_{a n}=120 \angle{ 80^{\circ}} \mathrm{V}Van=12080V, and the line impedance is zero, find the phase currents in the wye-connected source. -Ensure patient privacy and call for help and assist patient to bed once help arrives Use therapeutic communication/active listening D/C plan- decrease pain and restore normal gait. Check input/output for possible dehydration Virginia Smith -Restart the IV and draw CBC Pupils: PERRLA Size: R: mm L: _mm Unequal Sluggish Non-reactive Senario 2 Noncompliance: False Sensorium: Normal acuity, Bleeding, risk for: False The nest morning the gastroenterologist informs Mr. Gonzalez that his EGD confirmed a diagnosis of Barrett's esophagus with Dysplasia. Too bad the cruise area was a very unatractive part of the River Elbe. Endoscopic resection, which uses an endoscope to remove damaged cells to aid in the detection of dysplasia and cancer. Scenario 2 Scenario 2 The nurse observes an elderly lady who is crying and has not been taken care of yet. Knowledge Deficit True Ineffective Peripheral Tissue Perfusion False Contact charge nurse. RUE: ______________ LUE: _____________ Reassure patient and help explain any new orders from physician to patient LOC Normal acuity fallout 4 save wizard quick codes death and wheel of fortune tarot combination; gambling meaning in english urdu alpine spiced apple cider gluten free; how to use v2ray samsonas sequential gearbox subaru; lg magic remote power light stays on Scenario 3 Sexuality: True. Vital signs- Scenario 4 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. Scenario 3 Ramona Stukes, 69 yr-old, third day post-op cholecystectomy. Esteem Respiratory Rate: WNL Tachypnea Bradypnea Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. Mr. Greer has just been visited by his wife. Anxiety False Other: _______________________________ The patient is awake alert and oriented. Scenario 1 -Place patient on O2 Nasal Canula Patient demonstrates urine strain procedure. Report current urinary output quantify per hour and color of urine Notify Doctor for pain medz It is unclear if he lost consciousness. Cough: She has received a dose of Hydrocodone for PRN pain 20 minutes ago. Breath Sounds: Clear bilaterally. Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. Verify call light/ bed safety precautions Dr. Anderson, Educational Needs Increased acuity Scenario 2 Scenario 5 NKDA Assessment The client vital signs are: Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%, Neuro WNL alert and cooperative. Talk with her stating surgery is over and she did great. She has IV access and has received a small dose of Valium to reduce apprehension. Safety He is having some difficulty hearing and complains of ringing in his ears. Impaired comfort: True Psychological Needs Increased acuity Amount: _______ Her husband who is present states, "I thought it was just a lumpectomy she was having this morning." Take vital signs before leaving the hospital again. Monitor and evaluate fluid intake Visual assess They were also concerned about the next patient going into that room and the use of the lavatory. 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. Family arrive one hour after event to his prior room and find Mr. Thomason's room is empty and have no idea of the events that have just occurred. Scenario 1 Document results and findings Blood, Glucose 185, 4 units of insulin sliding scale for coverage. Scenario 1 However, these abnormal cells do not have the capability to spread to other parts of the body. After washing and gloving hands, you then identify yourself and the patient, Ann Rails. Filmotka filmu Najvyia ponuka (2013). Head/Face: Symmetric Asymmetric Drooping Color:__________ Disturbed Sensory Perception True He told the nurse that he has had some changes in his bowel habits and his stools have been very dark. Description: Sharp Stabbing Throbbing Aching Cramping Other: Palliative care. Notify lead nurse Scenario 1 Wash hands Love and Belonging Disturbed Body True Re-assess patient Wash and glove hands Scenario 1 Mr. Gonzalez has returned from his EGD and is still sleeping from the sedation. Impaired Comfort True -Tell the patient that they are being admitted to r/o any cardiac issues Decreased Cardiac/perfusion: False 20ga. Tunneled, site _______________ Implanted port, accessed _____________________ Impaired comfort: True The patient is asking you where her son is, the last place she saw him was right before the explosion. He is experiencing new onset of shortness of breath and has a nasal cannula with 2L of Oxygen in place. Remind the nursing staff that the patient is NPO. Stay with patient for surgeon's arrival to explain intended surgical procedure Scenario 5 Kathy Gestalt, 33yr-old, Dx- second day post-op open right Tibia/Fibula fracture, plaster cast in place on right lower leg. Scenario 1 He has been ruled out for an MI. But that's changing. Wash and glove hands Check PRN pain order Verify Call Light/Bed Safety precautions DSD (dry sterile dressing), forehead laceration clean and dry intact. Diet as tolerated. river part Answers to the questions; Fillable SOC 1 DLA 1; Fillable SOC 1 DLA 2 - Notes on Environmental effects through sociology . Temperature spiked during the night to 102.4, BP now 146/94 which is slightly elevated, respirations at 30 bpm and slightly labored, heart rate 102 versus 84 from last night shift. She receives the pre-op medication. Remain with patient Determine from medical record if partner is aware of his recent AIDS diagnosis. Risk for Infection True Impaired Mobility, Risk for True Scenario 1 You enter his room and recognize that Mr. Thomason appears to be talking to himself and appears confused. Document results Assist patient out of bed Ambulates with minimal assistance. Roger Clinton, 57-year-old male construction worker arrives at 0600 to be prepared for a partial thyroidectomy to determine if he has cancer. The dinner tray is waiting for the patient in his room, and the nurse notices it is a regular diet. Impaired Skin Integrity, Risk for True Assist physician in physical exam of patient Scenario 4 -Assess patient's understanding of the teaching and discuss home support, os de la main et de la ceinture pelvienne, Julie S Snyder, Linda Lilley, Shelly Collins. Replace oxygen nasal cannula that had become disconnected Fall Risk: Increased acuity Next time we'll spend our 60 on some food and nice beers. Scenario 5 Waist belt restraint PRN; family sitter at bedside, assist with bath. Self-Care Deficit False Knowledge Deficit True Full assessment Administer PRN constipation medications The Physician tells you to have everything ready including a 22 French chest tube, and he will be in shortly to position the chest tube. Fall Risk Increased acuity -Give NS liter bolus Physiological- Mr. Duncan's wife meets you in hall asking what she could bring her husband to eat from home. Adjust crutches Pain re-assessment His orthostasis is normalized after a second liter of NS was administered. Assume that the oxidation state of sulfur is 2-22 and that iron atoms exist in both +2+2+2 and +3+3+3 oxidation states. Fall, Risk for True Mr. Sturgess is recently diagnosed with metastatic cancer of colon and he and his family have chosen only palliative care. When you enter the room, the patient is having chest pain again, and they are pale and diaphoretic. Neuro WNL, except leg pain upon movement. Visual assessment Nathaniel Gonzalez Senario 3 : beach pearl), in walking distance of the velgnne ferry stop, is considered the mother of all urban beach clubs. The ER nurse reports that his cardiac enzymes were borderline, (Troponin?, CK/CKMB?) Failure to Thrive True. Disoriented, confused = 4 The patient states that the symptoms occurred in the middle of the night and woke him from his sleep. Love and belonging Scenario 2 Stoma Status: Pink-Red/Moist Dusky Retracted Excessive bulging Provide information for MD to call family at home and explain what has just happened Vital signs -Temp 98.6, BP 114/62, P 100, RR 20, SaO2 94%. Recent blood gases demonstrate falling PaO2 (hypoxemia) and increasing CO2 (Hypercapnia). Explain to physician what interventions you have recently initiated Two hours later, Mr. Duncan is asked how frequent his stools have been today. Therapeutic communicationT Notify doctor and charge nurse Mr. Richardson is requesting assistance to ambulate to bathroom. Upon assessment, you determined that she is confused to person, time, and place but is easily directable. The charge nurse tells the nurse to take Mr. Burgundy to the floor, because his room is now ready. LLE: Non-pitting Pitting ___+ Scenario 1 -Notify HCP of neuro findings Notify doctor Perform circulatory evaluation Paul Greer Senario 5 Comfort/Pain Assessment Crutches at bedside adjusted for height. -Notify HCP of fall, complete incident report Scenario 4 Increased fall risk. Scenario 4 Kathy Gestalt Peripheral Neurovascular Dysfunction False -Ensure there is a full O2 tank on the gurney, place patient on Nasal Cannula Since the finding was low-grade dysplasia and is considered the early stage of precancerous changes, the gastroenterologist recommends another endoscopy in six months, with additional follow-up every six to 12 months. Senario 1 Explain that he will probably not be going home at least until his doctor sees him. You enter room one hour after the physician has left the patient. Grieving True Dr. Brown, Educational Needs Increased acuity Scenario 3 Use therapeutic communication/Active Listening Until the recent diagnosis of cancer, the patient had only seen a physician once in the last ten years. Assess -Discuss and determine sitter availability Apply fall risk bracelet He states, "This is not serious." Dr. Sangerstien, Viola Cumble, 92yr-old, second day post-op hip repair, Allergic to Penicillin. Scenario 2 -Complete neuro checks as ordered Continent: Yes No Brief/Diaper Nathaniel Gonzalez Evaluate patient understanding He has not had his BP medication today. Notify lead nurse/doctor They wanted to know and pressure you for the information. Scenario 4 Reassure patient of options Multiple abrasions, bruising Head, chest, and inner thigh. There is an order to apply a waist belt restraint if needed. 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? Viola Cumble Assume role in response team of documenter The bed arrives tomorrow. Provide emotional support. Fall, risk for: True Upon entering room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." Opening Title Production company Cast and crew Genre J A N U A R Y 2: The Killing of John Lennon: IFC First Take: Andrew Piddington (director/screenplay); Jonas Ball, Krisha Fairchild, Gunter Stern, Gail Kay Bell, Mie Omori, Robert C. Kirk: Crime, Drama: 4: One Missed Call: Warner Bros. Pictures / Alcon Entertainment / Kadokawa Pictures: Eric Valette (director); Andrew Klavan (screenplay . Administer antipyretic meds 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. Full head to toe neuro assessment. Scenario 5 He also has a history of hypertension and takes Tenormin (Atenolol) and Atorvastatin (Lipitor). is a 57 y/o who has been admitted for a radical prostatectomy. Ms. Cumble is in bed and appears comfortable and requests assistance from you to get out of bed to go to the bathroom. She is also investigating bone marrow transplantation. -If cardiac is suspected call the provider and the rapid response team. Document results/findings Scenario 3 Reapply restraints He is pale, weak, diaphoretic, and appears anxious. Educate about recovery from appendectomy and care to wound. Chronic Confusion False You also notice the patient is more difficult to orient. Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. -Start IV Extends abnormally = 2 -Explain to the patient that he is now considered stable, you are taking him to the hallway, and he will be admitted to an impatient room within a few hours Safety- Document teaching moment. Scenario #2. Impaired Home Maintenance Management False 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! Combien gagne t il d argent ? Wife at bedside. Temp 98, BP 114/67, P 115, RR 20, SaO2 98%. Impaired Urinary Elimination True Provide comfort measures Ronald Burgundy Safety Increased acuity, Physiological Scenario 5 Impaired Skin Integrity, Risk for False