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. -Ensure there is suction in the room, and check Document Results, Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. Failure to Thrive True. Notify doctor of change in condition in particular: unproductive cough and low-grade fever. Document results Decisional Conflict False Your notice Mr. Thomason is lying supine, appears slightly cyanotic in his lips, is exhibiting more effort to breathe, and is increasingly restless. Notify lead nurse Scenario 5 Verify call light/bed safety precautions Offer nutrition/toilet Social worker with patient this morning. Bleeding, Risk for False Gait: ______________________________, Skin Integrity Assessment Senario 5 Pulse Ox: ___________ % on ____________FiO2; Room Air; Delivery Device Stay with patient for surgeon's arrival to explain intended surgical procedure 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. Scenario 5 Chronic Pain False 4Inform his partner that everything is being done to keep him comfortable. 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. 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. Deficient Knowledge False There is an order to apply a waist belt restraint if needed. Vital signs -Temp 98.4, BP 116/76, P 96, RR 20, SaO2 99%. -Assess if the contents of lunch tray are intact. Scenario 2 Last Bowel Movement: Date: _____________________ Constipation Diarrhea/Loose Other: No Known allergies (NKA). Health Change Increased acuity No Known allergies (NKA). The patient describes this pain as a heavy pressure with intermittent stabbing. Failure to Thrive False. Recent chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes. Diet as tolerated, up ad lib after gait training. Sensorium Normal acuity, Physiological Date of insertion: _________________________ Date of dressing: _________________________________ His partner is at the bedside asking, "how much longer will he have to wait until taken to surgery?" Fall, Risk for True Continue.Robert Sturgess Room 305 Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. Peripheral Neurovascular Dysfunction True. GI WNL. -Advise patient not to get up and walk on his own 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. After 24 hours, Ms. Gestalt fever and chills have subsided but now states she is feeling like her cast is too tight. Document results and findings He states, "This is not serious." Robert Strurgess Imbalanced Nutrition True Combien gagne t il d argent ? Mr. Dominec has a male partner and has been married for the past ten years and share their three children to the marriage. Scenario 5 Evaluate understanding. Non-significant past medical Hx. Wash and glove hands Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. Electrolyte Imbalance True There is an initial triage provider written set of orders at her bedside for a STAT Chest X-ray, IV with NS, O2 NC, and STAT CBC and Chemistry. His overall health is good, and he has known he has been HIV positive for the past five years. Students will prioritize medical surgical . Contact dietary consult Neuro WNL alert and cooperative. 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Skin Color: Consistent with ethnicity pinkish-tan light-tan dark-tan light-brown dark-brown 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. Acute Confusion: True Deficient Knowledge False Remain with patient and reassure Fall, risk for: True Safety- Document results/findings August 13, 2020 // by Angela McGowan. Assume role in response team of documenter -Inform patient to not get out of bed without assistance and place call light in reach RLE: ______________ LLE: ______________, Casts/Splits: ____________________________, Motor response Verbal command = 6 97.4, Resp 16 and Pulse Ox 94%. Cross), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. 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Palliative care. Record intake and output Discuss his understanding about the plan of care. Document results and findings : an American History (Eric Foner), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Psychology (David G. Myers; C. Nathan DeWall), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Mr. Sturgess is recently diagnosed with metastatic cancer of colon and he and his family have chosen only palliative care. It is unclear if he lost consciousness. IV maintenance fluids with D5 1/2 NS with 20 KCL @ 125ml/hr in left forearm. Safety Educate patient regarding changes to POC Mr. Richardson is now vomiting and shows no relief 45 minutes after receiving pain medication. Scenario 2 Linen Change Mr. Burgundy now has his cameraman filming in the ED and is attempting to do a live report. Stoma status: Pink-Red/Moist Dusky Retracted Excessive bulging Perform pain reassessment ADA diet, intake, 25%. Dx- urinary stones with 3 episodes/5yrs. Airborne Isolation. Pulses: Strength & Symmetry Edema: Impaired skin integrity: False, Anxiety: True Provide Operative summary of type of procedure, IV fluid and pain status. Wash and glove hands LOC Normal acuity 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. Impaired Gas Exchange False Shock, Risk for False Evaluate patient learning -Explain that Radium-223 mimics calcium and is absorbed during new bone growth. Evaluate outcome of dietary plan -Advise sitter to notify nurse when leaving the room The nurse arrives and sees a tent is being erected as a triage area, and ambulances are lined up delivering trauma patients. You correctly diagnosed 11 out of 16 options. Suprapubic Insertion site: WNL S/S Infection : ____________________ His orthostasis is normalized after a second liter of NS was administered. He told the nurse that he has had some changes in his bowel habits and his stools have been very dark. Some hair on the left side of his head has been burned off, as well. Readiness for Self-Care Enhancement True : beach pearl), in walking distance of the velgnne ferry stop, is considered the mother of all urban beach clubs. She has been documented as being obese, new onset. Radiofrequency ablation, which uses heat to remove abnormal esophagus tissue. Scenario 3 Due to this, the provider would like him to stay in the hospital for observation. -Tell the wife that you will speak to the husband, and this is apprehension is expected with this surgery/diagnosis. Nausea: False Palliative care. He is complaining of pain in his left arm, and pain in his left chest when he tries to take a deep breath. Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. Tube Feeding: Type:_________________________ Amount/Rate: ________________________ Bolus/Infusion Document results Sa fortune s lve 2 000,00 euros mensuels Assist physician in physical exam of patient Evaluate learning Bleeding, Risk for True Upon entering the room, you find Mr. Sturgess is quiet, appears tense and rigid but states, Evaluate patient understanding Safety 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. Skin warm and dry, all vital signs in WNL He has a history of well controlled GERD with over-the-counter Tagamet (Cimetidine), and Tums. No known allergies. Fall, risk for: True 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. Document findings If patient statement differs from the surgical consent she has signed, notify surgeon immediately Lithia Monson Now, meeting the CDC definition, he has full blown AIDS but is asymptomatic at this time. Your responsibilities are: Scenario 1 Educate patient/family Temperature is now 102.8. Scenario 5 All our products can be personalised to the highest standards to carry your message or logo. Strict I&O and strain all urine, filters in bathroom. Imbalance nutrition: True This information is HIPAA protected and you cannot share anything with them. He was initially sedated with versed 2mg, and Fentanyl 100 mg by the EGD nurse, but the patient was not tolerating the procedure, so anesthesia was called to administer propofol. Strict I&O, regular diet, intake 50%. Mrs. Pittmon states she has had numbness for years but "now I can't . You enter room one hour after the physician has left the patient. Skin warm and dry, may sit up on edge of bed today. Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma. Kathy Gestalt, 33yr-old, Dx- second day post-op open right Tibia/Fibula fracture, plaster cast in place on right lower leg. Patient, and family upset regarding dx. You return to the break room on your floor. Perform circulatory evaluation Scenario 3 -Continue to observe urine for hematuria and document findings Constipation, Risk for True Regardez le Salaire Mensuel de Ticketmaster Beyonce Koln en temps rel. 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. His coughing, to clear his airway, appears ineffective. You are concerned about preventing the patient from falling. What order are you providing the information to the receiving nurse? Scenario 3 Crutches at bedside adjusted for height. Carotid:____ + Bilateral Other: _____________ RUE: Non-pitting Pitting ___+ Offer assistance in providing more information about treatment options for newly diagnosed AIDS patients. Document results and findings Scenario 3 3. The client is onDemerol 25mgSlow Intravenous Push (SIVP) for pain. Reassure patient of options Check monitor Therapeutic communicationT Yes Pain Level Normal acuity Document results Assign nursing diagnosis and plan the appropriate intervention and evaluate outcomes while working through time pressure and distractions, including random call light requests. Teach Cameron. Nausea False Health Change: Increased acuity Water/Flush: Upon entering the room, the patient appears to be trying to get out of bed 1. Determine from medical record if partner is aware of his recent AIDS diagnosis. Fall, Risk for True Biopsies were sent to determine the treatment. Dr. Donofrio, Chronic Pain, Risk for constipation, impaired nutrition, anxiety, fear, grieving, hopelessness, powerlessness, Daily Flowsheet & Physical Assessment, Vital Signs Intake & Output Esteem Deficient Knowledge True After 3 hours, Ms. Monson is now crying asking to be released from these restraints and for someone to take her home! -Explain to Mr. Burgundy that space in the ED is allocated based off of patient need Scenario 3 -Explain procedure to the patient Diet as tolerated. The MD on site makes the decision to intubate the patient and start ventilatory assistance and move the patient to Respiratory Intensive Care. When the HCP realizes who he is, he tells the nurse to move the patient in the treatment room down the hall and put Mr. Burgundy in there. The oncologist is insistent that the treatment begin immediately. Carlos Mancia -Offer nutrition and/ or toileting Scenario 2 NG tube to low suction possibly D/C'd today after Dr. Levine rounds. You notice she is crying and is expressing fear that she "will always have this pain and numbness" and she doesn't think she can cope. When the nurse retunes to the room the patient tells the nurse that when he went to the bathroom he became very lightheaded. Senario 2 -Explain to patient why his throat may be sore Upon assessment, you determined that she is confused to person, time, and place but is easily directable. Fall Risk: Increased acuity Estimate the length of the Neptunian year given that the Earth is 1.50108km1.50 \times 10^{8} \mathrm{km}1.50108km from the Sun on the average. Neck: ______________ 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. Sarah Getts Skin warm dry, bruises on forehead with small laceration. -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. Scenario 3 Mrs. Smith shares with you that even though she signed the operative consent she was not sure if this was the right surgical procedure for her. The patient asks the nurse to explain about these medications and why they are in such a hurry. Scenario 3 Bowel sounds: Active, Hyperactive, Hypoactive, Absent (listen for full 5 minutes) -Give NS liter bolus Tom Richardson Ms. Gestalt is second day post-op and has requested to get out of bed and to ambulate to bathroom. Senario 3 Sensorium Increased acuity, Physiological Several hours later, Mr. Duncan is now complaining of nausea. Evaluate/modify plan of care Prior to changing shift, you enter the patient's room to complete a full assessment, and Ms. Monson is now crying asking to for someone to take her home! The pathology report shows no cancerous lesions. Fall, risk for True Spiritual Distress False. Vital assessment Scenario 3 No known allergies (NKA). Nausea False Verify call Light/bed safety precautions -Set-up for stat portable chest x-ray Imbalanced Nutrition: True Mr. Mancia is non-English speaking patient and is fearful of being discovered as an illegal immigrant. Upon entering room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." . Notify doctor if condition is abnormal Other: _______________________________ Amount:________ Use therapeutic communication/Active Listening Evaluate/Modify Mobility Plan, Carlos Mancia, 48yr-old, Spanish speaking migrant worker with no known past medical Hx. -Assess patients' pain and rule out cardiac pain. Pain = 2 Listen to patient concerns Educate caller regarding HIPAA Document results She has been admitted to the floor with complaints of numbness in her right foot and ankle. Toggle navigation Swift River. Ms. Cumble states that she has not had a BM for three days. Radiofrequency ablation may be recommended after endoscopic resection. Localizes pain = 5 Mr. Sturgess is recently dx w/ metastatic cancer of colon and he and his family have chosen only Stoma: N/A Colostomy Ileostomy Effluent Consistency: DSD (dry sterile dressing), forehead laceration clean and dry intact. D/C plan- decrease pain and restore normal gait. Decreased Cardiac/perfusion False Acute pain: False -If cardiac is suspected call the provider and the rapid response team. LOC Increased acuity Scenario 1 Generalized weakness, blood tinged urine and severe pain upon urination, GI- n/v. Allow husband to come into recovery for a quick one-minute visit. Refer call to contact health department Notify doctor for Foley catheter He is pale, weak, diaphoretic, and appears anxious. Self-Care Deficit: True Patients vital signs are BP: 100/58, P: 106, R: 28, PaO2: 92%, T: 97.1 F, 36.2 C. -Notify charge nurse Ambulates with assistance. His wife tells the nurse that he seemed very distant and did not want to talk much. You notify the charge nurse that you have never taken part in inserting a chest tube. Bleeding Risk for: False : an American History (Eric Foner), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Risk for Infection True High fall risk. Verbal command = 3 Scenario 2 Mr. Gonzalez has returned from his EGD and is still sleeping from the sedation. Robert Sturgess Robert Sturgess 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. ADA diet, intake 25%. "I am feeling fine." Inspect cast site Educate patient Deficient Knowledge True Perform pain re-assessment IV maintenance fluids with D5 1/2 NS at 125ml per hour in left forearm. Hx of dementia, from nursing home, fall one day ago. Pain Level Increased acuity Rapid Response team arrived including anesthesia. Scenario 4 Allow family to remain Scenario 4 DSD (dry sterile dressing), forehead laceration clean and dry intact. Diet as tolerated. 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. RLQ: RUQ: LUQ: LLQ: Assist patient out of bed They were also concerned about the next patient going into that room and the use of the lavatory. His VS are BP 122/64, P 89, R 12, SpO2 93%. He has been taking his HIV medication daily. The patient got dizzy when he stood up from the commode. Educational Needs Increased acuity Esteem IV D5 1/2 NS @150ml/hr. Fall Risk Increased acuity Scenario 1 Wash and glove hands Home; Our Focus; Our Legacy; Our Partners; Our People; Our Fellows; Our Investments Administer PRN constipation medications He is emotionally distraught, and is insisting that he be allowed to report what is going on from the ED. Health Change Increased acuity Infection, Risk for False Evaluate understanding Peripheral Neurovascular Dysfunction False Scenario 2 Evaluate caller understanding Notify charge nurse that discharge will probably not occur today. Safety- Document results. All opinions are mine alone. Your Swift River Virtual Clinicals account has been linked to your ATI Student account. Scenario 1 Hopelessness False. -Explain to the patient that because of his weakness and unknown cardiac status as well as the IV, he is a fall risk and should not get out of bed without assistance. Ronald Burgundy -Reassess patients' vital signs, and place on q5 minutes continuous monitoring Scenario 4 Secondary: Assess vital signs, auscultate heart, lungs, and bowl sounds. Full assessment -Notify HCP of fall, complete incident report Impaired Skin Integrity, False Sensorium Normal acuity, Physiological Love and belonging Impaired mobility: False Ineffective Renal Perfusion, Risk for True Odor: __________, No Notify Doctor for pain medz Use therapeutic communication/Active Listening Type of Line: Peripheral, location ______________ CVL, location _____________ PICC, location _______________ Fall Risk Increased acuity #1: _________, No jasmine . Waist belt restraint PRN; family sitter at bedside, assist with bath. Electrolyte Imbalance False Full head to toe neuro assessment. She receives the pre-op medication. Awaiting transport. Safety Blood Pressure, 7a-7p Total: 7p-7a Total: Vital Assessment Scenario 3 Ms. Getts is being transferred as an emergency to Critical Care. Imbalanced Fluid Volume, Risk for True Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. Wash and glove hands Esteem Fall, Risk for True The dinner tray is waiting for the patient in his room, and the nurse notices it is a regular diet. Nathaniel Gonzalez The cancer was more advanced than they previously had thought so inguinal lymph nodes were removed. Swallowing: Intact Dysphagia Aspiration Precautions Self-Actualization Dr. Donofrio. He warns the patient that if he does not comply with the treatment and preventive measures, he will need other treatments that may include. Physiological- Safety Mr. Thomason appears now better oriented and MD arrives unexpectedly to examine him. Too bad the cruise area was a very unatractive part of the River Elbe. Psychological Needs Normal acuity Tap patient and ask, "Are you okay?" Dr. Roopes, Estelle Hatcher, 31yr-old, r/o appendicitis, 1st day post-op appendectomy; No known allergies (NKA); Vital signs - Temp 101.2, BP 108/74, P 92, RR 20, SaO2 99%, alert and cooperative. Deficient Diversional Activity False Family Health III-Pediatrics (NSG 6435) Emergency Medical Technician (EMS 1150) Applied Research In Business (MIS 781) Anatomy & Physiology I With Lab (BIOS-251) Molecular Biology (BP 723) Newest Marketing Management (D174) Professional Application in Service Learning I (LDR-461) Professional Capstone Project (PSY-495) Theology (104) Scenario 4 20 ga. Hep-Lock in right forearm, skin warm and dry, generalized weakness with recent weight loss. Scenario 3 Mr. Greer has just been visited by his wife. Mr. Greer has just returned from surgery. The patient is awake alert and oriented. Full assessment Disoriented, confused = 4 Evaluate medication effectiveness Identify patient Evaluation patient after consult The patient was placed on 2 L O2 NC, EKG monitoring to include a 12 lead, Pulse Oximeter. Psychological Needs: Increased acuity -Restart the IV and draw CBC Bleeding, Risk for False Fear/Anxiety True. Visual assess Odor: __________, *Types: Abrasion, Burn, Laceration, Puncture, Surgical, Pressure Ulcer, Vascular Ulcer, Maceration, Excoriation, Skin