His wife tells the nurse that he seemed very distant and did not want to talk much. GI WNL. Auscultate peripheral pulses and ROM. Combien gagne t il d argent ? Love and Belonging If family/visitors come, will need education to airborne precautions. Offer masks to visitors student name date: nur 113 assessment swift river patient: robert sturgess handoff robert sturgess, 81 years old, metastatic ca of colon, hx of diabetes. 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. Sexuality: True. Ambulates with minimal assistance. -Complete neuro checks as ordered Until the recent diagnosis of cancer, the patient had only seen a physician once in the last ten years. Hx of dementia, from nursing home, fall one day ago. Decisional Conflict True Senario 2 Dysfunctional Gastrointestinal Motility False No known allergies (NKA). Water/Flush: The patient is awake alert and oriented. Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma. Anxiety True Senario 4 LUE: Non-pitting Pitting ___+ Dr. Altace, Educational Needs Increased acuity Wash and glove hands Sa fortune s lve 2 216,00 euros mensuels Mr. Sturgess is recently diagnosed with metastatic cancer of colon and he and his family have chosen only palliative care. Hopelessness True Document results Fall, risk for: True They were also concerned about the next patient going into that room and the use of the lavatory. Re-assess patient Wash and glove hands nursing care plan for Linda Pittmon, a 74 -year old female patient who is a noncompliant diabetic, and frequently stays at the local homeless shelter. Safety Dr. Rondeau, Educational Needs Increased acuity Palliative care. Safety Increased acuity, Physiological You are concerned about preventing the patient from falling. -Place patient on O2 Nasal Canula Assess for fall risk Taking HIV Meds prophylaxis. Heterotrophs include (1) autotrophs, saprophytes, and herbivores (2) omnivores, carnivores, and autotrophs (3) saprophytes, herbivores, and carnivores (4) herbivores, autotrophs, and omnivores. Dr. Donofrio, Physiological Encourage fluids/fiber/ambulation You are now preparing for discharge, place steps in order: Senario 1 The nurse observes an elderly lady who is crying and has not been taken care of yet. Imbalanced Nutrition: True Head/Face: Symmetric Asymmetric Drooping He requests no visitors at this time, but later asks for his family to be called to discuss a plan of care. Strict I&O, regular diet, intake 50%. Gastrointestinal Assessment Administer new pain medz Vital Signs: B: 160/92, P: 96, R: 22, SpO2: 98, T: 98.9F, 37.1C. 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. Scenario 2 Validate NPO Status Cough: Deficient Diversional Activity False No Known allergies (NKA). Provide verbal report to team members who respond to rapid response Scenario 4 Non-significant past medical history. Disturbed body False Document results and findings She is with her physician. Allow for non-compliance of request Combien gagne t il d argent ? Psychological Needs Increased acuity Noncompliance True. Listen to patient concerns Scenario 4 Nausea False Neuro WNL alert and cooperative. Begin post op education for day one He told the nurse that he has had some changes in his bowel habits and his stools have been very dark. Deficient knowledge: True Why is cysteine such an important amino acid for defining the tertiary structure of some proteins? Teach Cameron. Scenario 5 Scenario 1 Educational Needs Increased acuity Safety- Scenario 2 Escort patient to vehicle Psychological Needs Increased acuity Upon assessment, you determined that she is confused to person, time, and place but is easily directable. Reorient Patient to person, place, & time Ms. Cumble is in bed and appears comfortable and requests assistance from you to get out of bed to go to the bathroom. Retrieve cast removal tool You are told that he has intermittent chest pain with substernal burning that radiates to his mid-back. He replies, "six times in the past four hours". Scenario 1 Swift River Reflection Questions day 7 Answer each question thoroughly in multiple sentences. Observe closely first hour Wash and glove hands Scenario 5 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. ADA diet, intake 25%. Communication/Speech: Clear Non-verbal Slurred Aphasia Other Assist physician in physical exam of patient Educate patient regarding condition -Ask the patient if it is okay to discuss his care in front of his children. Noncompliance False Encourage fluids Scenario 1 Perform pain reassessment Wash and glove hands Full assessment Document results Insertion site: Dry/Intact Redness Tenderness/Pain Warmth Coolness Swelling Drainage Obtain translator This will treat any cancer that may have metastasized to the bone. Scenario 5 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. Insert Foley catheter Anxiety False Health Change Increased acuity No Known allergies (NKA). Therapeutic Communication -Elevate head of bed and place the patient on Pulse oximetry. Health Change Increased acuity Educate caller regarding HIPAA Administer antipyretic medication Assist patient out of bed Document findings Adjust crutches Scenario 2 Stools are decreasing but patient remains very weak. Capillary Refill: _________ seconds Pain and numbness in legs for one week. Scenario 3 Disturbed Body True Dr. Suculo, Physiological Remain with patient He also complains that his throat is still very sore. Educate patient/family Fear True Full assessment including both lying/standing Bleeding, Risk for False The nest morning the gastroenterologist informs Mr. Gonzalez that his EGD confirmed a diagnosis of Barrett's esophagus with Dysplasia. Dr. Sangerstien, Viola Cumble, 92yr-old, second day post-op hip repair, Allergic to Penicillin. Safety Decisional Conflict False RUE: ______________ LUE: ______________ D/C plan- decrease pain and restore normal gait. Fall, risk for: True Patient, and family upset regarding dx. Severe pain (10/10) medicated q 30 minutes x4 with IV Morphine 2mg with little relief. Psychological Needs: Increased acuity ASA is held but morphine 4 mg was given after his GI cocktail. Yes Attempt to orient to person, place, and time IV fluids of D5 1/2 NS are infusing at 100 mL/hour to his right forearm. Pulse Ox: ___________ % on ____________FiO2; Room Air; Delivery Device Senario 3 His partner is not with him at this time but will arrive soon to facilitate his discharge home. Educational Needs Increased acuity Inform patient about the progression and risk a PCP infection has for a patient with AIDS. An abc-phase-sequence three-phase balanced wye-connected source supplies power to a balanced wye-connected load. After 3 hours, Ms. Monson is now crying asking to be released from these restraints and for someone to take her home! Pain Level Increased acuity Educational needs: Increased acuity Fatigue True Combien gagne t il d argent ? RLQ: RUQ: LUQ: LLQ: August 13, 2020 // by Angela McGowan. He is emotionally distraught, and is insisting that he be allowed to report what is going on from the ED. In reassessing Ms. Monson, her vital signs are: BP -106/82, Temp-98.2, P-106, RR-18, SaO2-88. Electrolyte Imbalance False Neptune is an average distance of 4.5109km4.5 \times 10^{9} \mathrm{km}4.5109km from the Sun. His children are visiting, and they are very supportive. Scenario 5 No known allergies (NKA). RUE: ______________ LUE: _____________ The patient has a Foley catheter in place and is reporting 8/10 incisional pain and he is asking why his throat is sore. The client is onDemerol 25mgSlow Intravenous Push (SIVP) for pain. 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. Notify lead nurse/doctor 2Provide comfort in pre-surgical room Mr. Dominec. 2021-22, Historia de la literatura (linea del tiempo), Respiratory Completed Shadow Health Tina Jones, CH 02 HW - Chapter 2 physics homework for Mastering, BI THO LUN LUT LAO NG LN TH NHT 1, Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1. Encourage fluids and fiber diet Offer bedpan 1Perform full assessment and provide anti-nausea medicine. -Teach the patient that there are several interventions for complications post-prostatectomy to include erectile dysfunction, post-op prostatectomies, and self-care involved with a foley catheter at home. Spiritual Distress False. Therapeutic communicationT Dr. Altace, Physiological- Scenario 3 Eye opening Spontaneous = 4 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. He has been readmitted for a red spot on his sacrum of 1 cm and a 2 cm blister on his right heel. Safety Apply oxygen Acute pain: True Blood-tinged mucous, productive cough. Scenario 5 -Perform admission assessment Do not disturb Vital sign assessments -Discuss effectiveness of sitter Sa fortune s lve 2 216,00 euros mensuels BP 154/89, P 94 F, R 22, T 98.3F, SaO2 95% on room air. You now arrive in the recovery unit one hour post-surgery and you are told that the surgery went well. -Complete secondary assessment once the patient is in bed focusing on complaint of pain resulting from the fall The patient has sustained an injury to her head, that is bandaged, and is bleeding from a wound to her right arm and chest area. Senario 5 Her pitcher has already been filled three times this shift. Evaluate learning Skin warm and dry, daily dressing changes, T-tube without drainage. Swift River Clinical Practice Chamberlain University Expert James Moore Category: Nursing Description Full Document Jose Martinez Room 301 Jose Martinez, Jose Martinez, 43- year old male experiencing chest pain while watching a state rival football game earlier in the evening. Senario 4 Scenario 5 Senario 3 Scenario 4 Scenario 2 20 ga. Hep-Lock in right forearm, skin warm and dry, generalized weakness with recent weight loss. 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. IV maintenance fluids with D5 1/2 NS at 125ml per hour in left forearm. 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. Notify lead nurse/doctor Assess food consumption and intake and output Nausea: False Sa fortune s lve 2 000,00 euros mensuels -Take initial vital signs (room air Pulse Ox) You are the now the Surgical ICU nurse assigned to her. Carlos Mancia Enter the email address you signed up with and we'll email you a reset link. -Reassess patients' vital signs, and place on q5 minutes continuous monitoring Strict I&O and strain all urine, filters in bathroom. Two housekeepers, who were refusing to clean the room, are in the break room. Inform his partner that everything is being done to keep him comfortable. Scenario 4 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". GI WNL. -Verify that discharge orders have been written, provide discharge instructions, and in inform provider about the chest pain. Family in room with patient very concerned. -Tell the patient that they are being admitted to r/o any cardiac issues Administer pain medications 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. Describe the physical changes from aging and the care required. Arthur Thomason Imbalanced Fluid Volume, Risk for True Mr. Gonzalez has returned from his EGD and is still sleeping from the sedation. Ms. Rails shares with you her fear of being discharged home to an abusive husband. Acute Confusion True Yes Infection, risk for: False. The patient will be discharged today, and he will be ordering new prescriptions. Document results, Care of the Patient with a Cardiovascular or, NCLEX - Care of Patient with an Immune Disord, Quiz: Chapter 54, Care of the Patient with an, Chapter 54: Care of the Patient with an Immun, Chapter 17, Section 5; Providing First Aid fo. They would also like to start Radium-223. The patient has a pneumothorax that requires a chest tube placement. His original lymph node biopsy was negative. Vital signs -Temp 98.2, BP 94/60, P72, RR 22, SaO2 99%. No known allergies (NKA). Don Personal Protective Equipment Ms. Cumble states that she has not had a BM for three days. Verify Call Light/Bed Safety precautions Safety -Assess patient's ABC (airway, breathing, circulation) Infection, Risk for True Ms. Getts is requesting water to drink. Diet as tolerated. She has just been transported from recovery. Stay with patient for surgeon's arrival to explain intended surgical procedure Scenario 5 Observe closely first hour except 115 pulse, which is normal for him. Temp 98, BP 114/67, P 115, RR 20, SaO2 98%. 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. Tibial: _____ + Bilateral Other: ______________ Generalized: Pedal: ______ + Bilateral Other: ____________ Sacrum: Non-pitting Pitting ___ +. Cryotherapy, which uses an endoscope to apply a cold liquid or gas to abnormal cells in the esophagus. Fall Risk: Increased acuity Swift River Medical-Surgical. 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 You enter his room and recognize that Mr. Thomason appears to be talking to himself and appears confused. Regular diet. John Duncan, 56yr-old male, Dx- Gastroenteritis, returned yesterday from Cancun, c/o intractable diarrhea, weak, pale, and refusing to eat. Self-Care Deficit True While assessing the patient, Mr. Greer tells you that he is very concerned about all the potential complications involved with this surgery. The nurse arrives and sees a tent is being erected as a triage area, and ambulances are lined up delivering trauma patients. Pain Level Increased acuity Stoma status: Pink-Red/Moist Dusky Retracted Excessive bulging Lung sounds are worse. After leaving the room the provider tells the nurse that he hopes that he scared him into compliance with the treatment options. Extends abnormally = 2 Sleep Deprivation False 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. Abdomen: Flat Rounded Scaphoid Distended Palpation: Soft Taut Rigid Noncompliance: False Chronic Pain False You enter room one hour after the physician has left the patient. Talk with her stating surgery is over and she did great. Chronic Confusion False Scenario #2. Evaluate understanding IV maintenance fluids with D5 1/2 NS with 20 KCL @ 125ml/hr in left forearm. Evaluate outcome of dietary plan Acquire daily weight and food intake -Provide the patient with the time when HCP will come discuss options with him -Provide a diversional activity to pass the time while waiting on the HCP and inform wife that the HCP will be coming soon Today, clubs like Hamburg City Beach Club, Lago Bay, Hamburg del Mar and StrandPauli provide a relaxed summer atmosphere with a view over the Elbe. Senario 4 Respiratory Rhythm: Regular Rhythmic Irregular Periods of Apnea Cheyne-Stokes Obtain translatorT -Offer nutrition/toilet DSD (dry sterile dressing), forehead laceration clean and dry intact. Administer PRN constipation medications The emergency bathroom light goes off and the nurse finds Mr. Greer on the floor in the bathroom. 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! Provide comfort and pain measures Pain re-assessment Failure to Thrive False. Full assessment of patient. Report to charge nurse/ head nurse the need for staff education. His orthostasis is normalized after a second liter of NS was administered. Secondary: Assess vital signs, auscultate heart, lungs, and bowl sounds. You arrive in room to check on her, after washing hands. 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. Palliative care. Physiological- Educate patient 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. Verify call Light/bed safety precautions -Reorient Patient to person, place, & time Notify doctor if condition is abnormal Rapid Response team arrived including anesthesia. Fall, Risk for True SANE nurse to make second visit today. 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 . 0800 1200 : beach pearl), in walking distance of the velgnne ferry stop, is considered the mother of all urban beach clubs. Offer assistance in providing more information about treatment options for newly diagnosed AIDS patients. Full head to toe neuro assessment. Elevate head of bed Educational Needs Increased acuity Contact dietary consult When the nurse retunes to the room the patient tells the nurse that when he went to the bathroom he became very lightheaded. Combien gagne t il d argent ? Impaired mobility: False Use therapeutic communication/Active Listening Hep-Lock in place left AC. Mr. Sturgess is now declining, and family members are requesting to remain in room past normal visiting hours. Grieving False Bleeding False All opinions are mine alone. Review pain medication order Electrolyte Imbalance False Insertion Site: Dry/Intact Redness/Erythema Drainage Tenderness Maceration Alert and cooperative. You are about to call the Surgical ICU and give report. Health Change Increased acuity Refer call to contact health department Chronic pain: True 50% intake. Scenario 3 Love and Belonging Scenario 4 Tear, Ecchymosis, Contusions, Bruising Apical Pulse Rate: Heart Sounds: Normal S 1 S 2 S 3 Senario 2 Scenario 2 Apical pulse rhythm: Regular Irregular Location: Document findings/results, Ann Rails, 38 years old, c/o back pain, non-significant past medical history. Verify call light/bed safety precautions Fall Risk Increased acuity Senario 2 Reassure patient of options Sit at an eye level. Suprapubic Insertion site: WNL S/S Infection : ____________________ Therapeutic communication John Duncan Vital signs -Temp 98.6, BP 114/62, P 100, RR 20, SaO2 94%. Background Robert Sturgess the client was admitted with Metastatic cancer of Colon, with history of diabetes. Document results/findings Offer assistance Oriented to: Person Place Time Employ therapeutic communication: present reality LOC Normal acuity Imbalanced Nutrition True Scenario 2 Notify doctor for Foley catheter Incomprehensible Endoscopic resection, which uses an endoscope to remove damaged cells to aid in the detection of dysplasia and cancer. Impaired Skin Integrity False Document and provide copy for Mr. Dominec to share with his follow up appointment tomorrow. Visual assess -Draw a repeat CBC per HCP order to determine current Hemoglobin status Mr. Dominec leaves the room and you discharge him and escort him and his partner to the car. Nathaniel Gonzalez jessdevan. Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. Evaluate understanding Ambulates with assistance. Spanish interpreter available at extension 61178. Patients vital signs are BP: 100/58, P: 106, R: 28, PaO2: 92%, T: 97.1 F, 36.2 C. Scenario 3 Ineffective Airway Clearance True Scenario 5 Inappropriate words = 3 Mr. Sturgess does not have a living will or durable power of care completed. Palliative care. He is married, and his wife is requesting to stay at his side. Wash and glove hands Ineffective self-health mgmt: False, Disturbed body: False -Complete head-to-toe assessment while patient is on the floor. Assign nursing diagnosis and plan the appropriate intervention and evaluate outcomes while working through time pressure and distractions, including random call light requests. How was this -Notify HCP of fall, complete incident report He tells the nurse he has called his wife and wants to be discharged now. -Assess patients' pain and rule out cardiac pain. Notify doctor No Known allergies (NKA). He warns the patient that if he does not comply with the treatment and preventive measures, he will need other treatments that may include. Wash and glove hands Sensorium Increased acuity, Physiological Notify lead nurse/doctor Fear True Fall, Risk for True Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions StuDocu University Keiser University Western Governors University Scenario 4 Recently he manifested an unusual black lesion on his thigh and developed an opportunistic fungal mouth infection which was treated successfully. Put the patient on O2 NC and Fentanyl 25mcg IVP for pain. Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. He does not have an IV nor is he on oxygen. Mr. Gonzales H/H is 12.7/38. Amount: _______ Love and belonging- Bleeding, Risk for True Tubes: None Salem Sump Nasoduodenal PEG J-Tube pH: ______ No weight bearing today. Impaired Mobility False Tom Richardson Sitting, BP 109/60, P 114, Standing the patient becomes very lightheaded and the nurse has them lay back down. Vital Assessment 3Check surgical consent for correct procedure and make sure operative site is marked. Document results -Ensure the bed is in lowest position, the side rails are up, the call light is in reach, and ask the patient if they need anything before you leave the room Paul Greer -Inform Mr. Burgundy that he cannot report from the ED, as patient privacy is strictly protected by HIPPA If patient statement differs from the surgical consent she has signed, notify surgeon immediately Peripheral Neurovascular Dysfunction True. Psychological Needs Normal acuity No Known allergies (NKA). Ms. Rails states that she has not had a bowel movement (BM) in the past two days. -Ensure there is a full O2 tank on the gurney, place patient on Nasal Cannula Ineffective Self-Health Management True Stoma Status: Pink-Red/Moist Dusky Retracted Excessive bulging Cross), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Week #7 Assignment - Incentive Spriometer . He was recently treated for a URI with a Z pack, prednisone, and Motrin for pain. The patient was placed on 2 L O2 NC, EKG monitoring to include a 12 lead, Pulse Oximeter. The cancer was more advanced than they previously had thought so inguinal lymph nodes were removed. Upon entering room, you wash/glove hands. Fall, risk for True Acute Pain True Deficient knowledge: True Remind the nursing staff that the patient is NPO. Scenario 2 Bed Bath: Assist or Total Check PRN pain order Mr. Dominec had his surgical procedure and is doing great. But that's changing. Imbalanced Nutrition False Scenario 1 Scenario 4 Scenario 2 Your Swift River Virtual Clinicals account has been linked to your ATI Student account. Reassure patient and help explain any new orders from physician to patient Scenario 2 Oral Mucosa: Tongue: Teeth: Fall, risk for: 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.

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