No known allergies (NKA). 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. Eye opening Spontaneous = 4 Notify Physical Therapy (PT) Mr. Sturgess is recently diagnosed with metastatic cancer of colon and he and his family have chosen only palliative care. Mr. Richardson is requesting assistance to ambulate to bathroom. The nurse performs tilt test, Patient vital signs lying flat, BP 118/62, P 92, R 20, T 98.5, SpO2 97. Toileting, Medications List/Times of Medications/Routes of medication, Neurological Assessment Obtain recent chest X-ray reports and recent ABG's for physician to review Grieving: False. 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. Palliative care. 00 Comments Please sign inor registerto post comments. When you enter the room, the patient is having chest pain again, and they are pale and diaphoretic. Scenario 4 Use therapeutic communication/Active Listening 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. Wash and glove hands Scenario 1 Apical pulse rhythm: Regular Irregular Location: -Reassess patient She has IV access and has received a small dose of Valium to reduce apprehension. Nausea: False Verify call light/bed safety precautions Senario 3 Senario 4 -Offer nutrition/toilet Esteem Impaired comfort: True His overall health is good, and he has known he has been HIV positive for the past five years. Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. She is with her physician. Blood Pressure, 7a-7p Total: 7p-7a Total: 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! Communication/Speech: Clear Non-verbal Slurred Aphasia Other Scenario 5 Students will prioritize medical surgical . Document results Students also viewed Culture Concept notebook Development concept notebook Elimination concept notebook Gas Exchange concept notebook -Using therapeutic communication inform Mr. Greer that there are many treatment options, and not to leave until the HCP can come and speak with him ADA diet, intake 25%. Safety Health Change Increased acuity Scenario 3 Scenario 3 The surgeon has suggested Androgen-deprivation therapy (ADT) with surgical castration (orchiectomy). Acquire daily weight and food intake This shop has been compensated by Inmar Intelligence and its advertiser. -Remind patient to call for help is he need to get up and provide patient with a urinal. Read PT report Psychological Needs Normal acuity Educational Needs Increased acuity Scenario 1 156 terms. RLQ: RUQ: LUQ: LLQ: Administer protocol antidiarrheal medication 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. He does not want to return to the nursing home, and does not wish to burden or live with his children. Description: Sharp Stabbing Throbbing Aching Cramping Other: Tap patient and ask, "Are you okay?" Senario 4 Neuro WNL alert and cooperative. The bed arrives tomorrow. Wash and glove hands -Reinforce to the patient to not get out of bed Contact Social Services He is married, and his wife is requesting to stay at his side. Imbalance nutrition: True If family/visitors come, will need education to airborne precautions. Bladder distention Pelvic pain Low back/flank pain "I am feeling fine." He is restless with slight confusion but is easily orientated with attempts from nurse. Replace oxygen nasal cannula that had become disconnected Localizes pain = 5 Scenario 5 Nathaniel Gonzalez Neuro WNL alert and cooperative. -Verify that discharge orders have been written, provide discharge instructions, and in inform provider about the chest pain. -Ensure bed is in lowest position, and rails are in place -Start an IV No known allergies (NKA). 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 . LOC Increased acuity -Complete head-to-toe assessment while patient is on the floor. Senario 5 Pain Scale: 0 to 10: _______________ Scenario 2 Scenario 1 Provide information for MD to call family at home and explain what has just happened He replies, "six times in the past four hours". Physiological- Pain re-assessment Scenario 2 The patient was placed on 2 L O2 NC, EKG monitoring to include a 12 lead, Pulse Oximeter. Mr. Mancia's vital signs upon assessment are Temp 101.2, P 94, RR 20, BP 122/82, SaO2-91%. He is complaining of pain in his left arm, and pain in his left chest when he tries to take a deep breath. Safety- Impaired Home Maintenance management r/t client or family False Assume role in response team of documenter Call rapid response Love and belonging , a 58-year-old male patient presents to the ER CO CP 10/10. Attempt to orient to person, place, and time The nurse observes an elderly lady who is crying and has not been taken care of yet. Assess food consumption and intake and output Upon assessment, you determined that she is confused to person, time, and place but is easily directable. What is the ratio of Fe\mathrm{Fe}Fe (II) atoms to Fe(III) atoms in this compound? Disturbed Body Image True Notify lead nurse/doctor Educational Needs Increased acuity Sensorium Normal acuity, Physiological Excess Fluid Volume, Risk for False The ER nurse reports that his cardiac enzymes were borderline, (Troponin?, CK/CKMB?) Scenario 2 Allow for non-compliance of request Scenario 4 Mrs. Pittmon states she has had numbness for years but "now I can't . Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. But that's changing. Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. Hopelessness False. Health Change Increased acuity Blood Glucose 185, 4 units of insulin sliding scale for coverage. He tells the nurse he has called his wife and wants to be discharged now. Scenario 5 Apply restraint -Take initial vital signs (room air Pulse Ox) Students will form a preliminary assessment based on reported assessment data for medical surgical patients in a virtual clinical environment. 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. It is now third day post-op, the order is for Ms. Cumble to stand by bedside on both legs for 5 minutes, three times a day. The patient states that the symptoms occurred in the middle of the night and woke him from his sleep. He told the nurse that he has had some changes in his bowel habits and his stools have been very dark. Pain Level: Increased acuity Scenario 2 Impaired Home Maintenance Management False -Transport Mr. Burgundy to his room 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. Offer nutrition/toilet Odor: __________, *Types: Abrasion, Burn, Laceration, Puncture, Surgical, Pressure Ulcer, Vascular Ulcer, Maceration, Excoriation, Skin 1. Decreased Cardiac/perfusion: False Assess Inappropriate words = 3 jessdevan. Scenario 1 They were also concerned about the next patient going into that room and the use of the lavatory. Bleeding False Impaired Skin Integrity, False Perform full assessment and provide anti-nausea medicine. Document results and findings LOC Normal acuity Verify call light/ bed safety precautions After leaving the room the provider tells the nurse that he hopes that he scared him into compliance with the treatment options. -Continue to observe urine for hematuria and document findings The oncologist is insistent that the treatment begin immediately. Educate patient Administer PRN constipation medications Cardiovascular has pacer with rate of 82bpm on demand. Awaiting transport. Impaired Mobility True Monitor and evaluate fluid intake Increased fall risk. Enter the email address you signed up with and we'll email you a reset link. Reapply restraints All our products can be personalised to the highest standards to carry your message or logo. Safety- Scenario 1 Re-assess patient Evaluate patient learning Urine Color: Clarity: Odor: Deficient Fluid Volume True Fall Risk Increased acuity It is determined that Mr. Sturgess could achieve better pain control w/ a PCA pump Evaluate/Modify Mobility Plan, Carlos Mancia, 48yr-old, Spanish speaking migrant worker with no known past medical Hx. You enter his room and recognize that Mr. Thomason appears to be talking to himself and appears confused. Wash and glove hands Iron forms a sulfide with the approximate formula Fe7S8\mathrm{Fe}_7 \mathrm{~S}_8Fe7S8. IV D5 1/2 NS @150ml/hr. Safety Ms. Rails shares with you her fear of being discharged home to an abusive husband. -Check on patient/sitter hourly Scenario 3 -Advise sitter to notify nurse when leaving the room Fall, Risk for True Acute Confusion True Your coworkers are asking you questions about Mr. Dominec. Ms. Rails states that she has not had a bowel movement (BM) in the past two days. Imbalanced Nutrition False Scenario 5 Offer assistance in providing more information about treatment options for newly diagnosed AIDS patients. Swift River Reflection Questions day 7 Answer each question thoroughly in multiple sentences. Skin Integrity: Intact No, describe below, Location Type Size Wound bed Drainage Scenario 3 Pain Level Increased acuity Scenario 5 When completing the shift change neuro check, you notice the patient's left pupil is sluggish. Ineffective Self-Health Management True Noncompliance: False Scenario 4 The provider advises the Nurse to draw a stat CBC, give a liter bolus of NS, and repeat CBC. Impaired Skin Integrity, Risk for False Document results BP 154/89, P 94 F, R 22, T 98.3F, SaO2 95% on room air. 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. Skin moist, respiratory bilateral wheezes and rhonchi. Peripheral Neurovascular Dysfunction: False Recent blood gases demonstrate falling PaO2 (hypoxemia) and increasing CO2 (Hypercapnia). Ms. Getts is requesting water to drink. Do not probe further -Attempt to orient to person, place, and time Obtain and provide the infectious disease doctor's contact information for him. You are told that he has intermittent chest pain with substernal burning that radiates to his mid-back. He was recently diagnosed with stage III prostate cancer. -Reinforce the risk if patient has not been NPO and ask the patient when the last time they ate. Acute pain: True Inform and educate spouse of dietary orders Scenario 1 Wash and glove hands Evaluate understanding She has arrived in pre-op and about to have surgery this morning. Continue.Robert Sturgess Room 305 Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. Pain Level Increased acuity Scenario 2 Dr. Donofrio. Assign nursing diagnosis and plan the appropriate intervention and evaluate outcomes while working through time pressure and distractions, including random call light requests. Assess for fall risk Perform neuro assess Verify Call Light/Bed Safety precautions Love and Belonging 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. Constipation, risk for: True Educate patient She is also to receive radiation, chemotherapy, and hormone therapy post operatively. Also worth mentioning is the 'Alter Schwede' - a 217t . Assess for bowel sounds No Known allergies (NKA). ASA is held but morphine 4 mg was given after his GI cocktail. Report this activity immediately to the hospital privacy officer Apply fall risk bracelet Scenario 4 -Assess patient's ABC (airway, breathing, circulation) You explain that his condition has worsened and now he has been taken to ICU. Impaired Skin Integrity, Risk for False Where is my camera man!! -Give NS liter bolus Therapeutic communicationT A GI cocktail was administered, and the patient stated that it decreased his pain to a 6/10. The patient is asking you where her son is, the last place she saw him was right before the explosion. You return to the break room on your floor. Describe the physical changes from aging and the care required. The impedance per phase in the load ist 14+j1214+j 12 \Omega14+j12. Acute Pain True -Reassure patient that he will be moved to a private room as soon as possible Dx- urinary stones with 3 episodes/5yrs. Request time she can arrive and staff to help with transfer Scenario 2 Notify doctor Scenario 5 Robert Sturgess Robert Sturgess 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. GI WNL. Scenario 5 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. Mr. Sturgess does not have a living will or durable power of care completed. Respiratory Rate: WNL Tachypnea Bradypnea -Document and contact nursing supervisor/Charge nurse