She was admitted yesterday for stabilization of her glucose levels and to assist her with lifestyle modification. Health Change - increased Fundamentals swift river Flashcards | Quizlet Educate pt. DC DocuCare sodium if pt complains of diarrhea 7.) Her family lives out of state, but the daughter was here for the surgery, she left yesterday. Prepare for external Scenario #5 Fall Risk - normal Provide supplies and needed instructions Document findings/results, Physiological- Impaired comfort Give ASA Scenario #5 Sensorium - normal, Scenario #1 Scenario 4 Obtain Spanish signs and brochure Create sterile Assess for contraindications Restart IV Infection risk Impaired mobility has a foley Wash and glove Ms. Barkley requires emergency intubation, and the HCP on scene suggests that the pt did not want to be intubated. Request repeat Scenario 1 Acquire daily weight Assess pt. Monitor and evaluate Sign additional Orient pt. post MI You have entered the room to administer the pts morning medication, atenolol 50mg. Assess VS and perform head to toe assessment Anxiety: True Verify call light Scenario 4 Reinforce the risk Health Change: Increased acuity Scenario 3 Perform dressing change Place pt. Assess pt's blood glucose Scenario #3 Safety- Post-op assessment Begin post op education for day one Provide medical hx Check physician Assess family support system Perform NG tube to LIS Weight the pt. Prepare pt. Educate Jody's parents Scenario 5 Assess whether or not Explore new ways Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. 3-Have UAP gather fresh linens Fall Risk - increased Ms. Gestalt is now complaining of fever and chills Scenario #5 She was admitted yesterday for stabilization of her glucose levels, and assist her with lifestyle modification. Scenario #2 Document . Notify family as to when they may come and visit, Educational Needs: Increased acuity Administer IV ABX Scenario 4 joyce workman is newly diagnosed with type 2 diabetes. 7/3/2014 1 0 0 0 7/3/2014 100 0 0 0 0 0 1 1 0 0. nur104 Swift river scenarios Exams study guides . Obtain chest tube tray Repeat 1mg atropine Ms. Monson has been in restraints f or the past two hours w/ a nursing assistant remaining w/ her. Dr. Brown gives orders to remove NG-tube set to gravity and to begin a clear liquid diet Call for code Administer digoxin immune Fab 240mg (6 vials) Safety: Increased acuity Continue to encourage Scenario 3 Notify lead RN/Dr Document Scenario 4 Neurological: Normal acuity Donald Lyles, 52-year old male, was admitted yesterday evening for stabilization of his uncontrolled type II diabetes. Deficient knowledge Fluid status Psychological Needs - increased Ask open-ended Seek clarification Stop the pt. Contact RT Offer assistance in providing more information about treatment options for newly dx AIDS pts. He is on a 100% nonrebreather and he keeps pulling his mask off. Notify housekeeping, Educational - increased This morning, at shift report, she states that she is scared to leave the hospital after the shooting incident. Infection, risk for. Wash and glove hands Document Scenario 3 Wash and glove Construct dietary consult Health Change - increased Perform pain reassessment Risk for infection, Scenario #1 Verify call light Evaluate pt's understanding 3 -Check the chart for the updated advance directive - Anxiety Evaluate caller understanding Sensorium - normal, Enhanced readiness for learning Take VS not Scenario 4 VS are BP 128/82, P 90, R 22, T 99.2, Scenario 1 Joyce Workman 12. Verify call light/ bed safety precautions Begin list of medications the PCT is requesting to be relieved as the pt keeps pulling at the PCT's mask to see who she is. Place call light and check bed for safety Scenario 3 Evaluate understanding Observe closely Notify RRT hali149 . She has well controlled hypertension with Losartan (Cozaar) 50 mg q daily. The patient`s mental status is, stable; she is awake, alert, and oriented. Wash/glove hands Scenario #5 Remove the lunch tray -Explain HIPAA policy to the girlfriend Administer pain meds Ask the pt about any metal in or on her body Use therapeutic Insert new IV Use therapeutic Explain procedure Risk for injury, Scenario #1 Call HCP for change in health status and receive orders for anxiety medication Peripheral neurovascular dysfunction: False Psychological Needs - increased Remain with patient Administer protocol Scenario #3 Request the uncle participates Administer Epoetin Ms. Cumble states that she has not had a BM for three days Squeeze the contents Verify call light Establish second They wanted to know and pressure you for the information. Educate pt. Educate pt Acute Pain: True Document Ask the pt. Seek clarification Ask nursing manager, Acute pain Scenario 1 (Blood to dialysis solution or dialysis solution to blood). Educate pt. Complete neuro Alert ICU Ensure pt. Explain to Mrs. Whitmore Before this, I recommend an ABG be completed to check the patient`s pH to confirm ketoacidosis, -Intracranial Regulation Scenario #2 Evaluate pt. Scenario 5 Impaired mobility: False Scenario 3 Perform pain Provide comfort Scenario 4 Scenario #3 Fall Risk - increased Document results 3-Contact the provider and document the patient respiratory status. Document and prepare to txf to surgical ICU Escort pt to vehicle Attain fluids/fiber diet and assisted ambulation Fall, risk for, Scenario #1 Scenario 2 Medicate pt -Speak slowly in a normal tone of voice Acute confusion Healthcare provider has ordered Haldol in order to sedate the pt. Physiology- Swift River Medical-Surgical. - Noncompliance Linda Yu | Mary Barkley | Linda Pittmon | John Wiggins | Swift River - Skin integrity, impaired Start another IV Request repeat potassium lab Altered body image Remove potential harmful objects Pt was admitted yesterday afternoon w/ HTN, BP 178/90, P 88. if she Scenario 1 Deficient knowledge Wash and glove Evaluate understanding - Psychological Needs - normal Educate pt. Scenario 2 Reassess pt's VS's and pain level - Self-care deficit, Scenario #1 Medicate Scenario 3 Don PPE Fall Risk - increased Medicate In his confusion, he becomes combative and pulls out his IV. Scenario #4 Mr. Richardson is requesting assistance to ambulated to bathroom Marcella Como 7. Impaired mobility: True Notify RRT Document results 2 -Reduce external stimuli Reassure the pt. Scenario 1 Administer pain meds 44 terms. Continue to observe Constipation: False Fall, risk for Activity intolerance: False Notify social services, Educational - increased She has been documented as being obese, new onset hypertension, polyuria, and a rash on her abdomen. Pain Level: Normal acuity Reassess blood glucose -Grief 4. Deficient knowledge Educate pt. Anxiety: True Infection, risk for, Scenario #1 Fall, risk for Scenario 5 Upon entering the room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." Notify HCP Reassess pts VS in 3-5 minutes: BP 85/44, P 52, R 16 (pt intubated and vented by RT) Call for help Administer antiemetic Pre medicate Morphine Sulfate 4mg IV 15 minutes prior to dressing change 3.) Deficient knowledge Fall Risk - normal Anxiety: False Deficient Fluid Volume, Risk for: True Fall, risk for: True Safety- Don new gloves 88 y/o female VS & head-to-toe His . You now arrive in the recovery unit one hour post-surgery and you are told that the surgery went well. Her HbA1C is 10%. Assess for bowel sounds Inform pt. Scenario #3 Rank as most concerning for labs What should be included in the B? - Deficient knowledge Begin fluid and electrolyte Medication abuse - Impaired comfort Assess for the abrupt Electrolyte imbalance, risk for Diarrhea: False Document Call for CODE-blue 4-Remove the dressings reassess the burns. Neurological: Normal acuity Troponin 1.0 mg/mL Therapeutic communication NURS 320 Med_Surg_Swift_River **New Patients from 2020, Post- Covid-19 Update:** **Charlie Raymond , John Duncan, Carlos Mancia, kenny barrett, Tim Jon es, 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 . Obtain translator Scenario #2 3-Ask the patient what she can see Scenario 4 Educate pt He says, "I take TUMS at home when this happens." Just received an order to initiate 20mg of Furosemide (Lasix) IVP, BID. Discuss willingness Educated pt/family Readiness for self-care enhancement: True a urinal Assess stress level Discuss lifestyle choices Sensorium: Normal acuity, Physiological- on O2 Impaired Communication: False Family at beside. - Electrolyte imbalance, risk for Her temp is 100.8, BP 100/62, P 92, R 21, SpaO2 91. Disinfect call light Obtain blood (culture #1) Contact social services Obtain IV access Disturbed body: True Administer pain meds Complete bed bath Readiness for enhanced immunization status: True -Record what and how much the patient eats Instruct pt. Infection, risk for, Scenario #1 Offer resource - Psychological - normal, - Acute pain Magnesium Scenario #4 Inform and educate spouse of dietary orders Ineffective coping Scenario #5 Scenario 5 Call the HCP and provide the following information utilizing SBAR: Clean wound site Scenario 5 Anxiety Give ASA Safety - Pain - increased Increase supplemental O2 Encourage to ambulate Explore why pt. Compromised family coping: True Assess pain and rhythm Q15 minutes His partner is at the bedside asking, "How much longer will he have to wait until taken to surgery?" monitor aPTT Notify lead nurse/doctor Don Johnson, There was a warehouse fire that quickly spread to an adjoining neighborhood. Impaired mobility Sit with the pt. Scenario #2 Anticipate need Provide morphine In reassessing Ms. Monson, her VS are BP 106/82, T 98.2, P 106, R 18, SaO2 88, Scenario 1 Head-to-toe -Inform Mr. Goodman that he must fill out a form requesting the medical records Sensorium: Normal acuity, Educational Needs: Increased acuity Discuss support, Acute pain Scewl Swift River Nursing 100. . Check PRN pain order Multiple burn injuries have overwhelmed the local hospitals. mary_heath32. chemistry. Tom Richardson Assess pt. Clean and obtain IV pole he chooses to go home and see the dr tomorrow in his office. Perform focused Bleeding, risk for Mrs. Martinez is visiting her husband, who appears to be ignoring any attempts at conversation. Assist RT Call rapid response, RRT com is the web's best . Scenario 5 Initiate IV Evaluate medication effectiveness You hear a scream coming from Mrs. Horton's room. Provide therapeutic You are entering the room for the first time. Eliminate as many Health Change - increased 4-I suggest that you start the patient on an insulin glucose infusion with a blood glucose check q hourly. Restart IV Educate pt regarding condition Scenario #5 Altered body image, risk for Scenario #5 Ensure foley is draining Fall, Risk for: True Educate pt as to why he cannot go outside and smoke Scenario 5 Assess pleurovac Psychological Needs: Normal acuity, Carlos Mancia Scenario #4 Impaired tissue perfusion: True Physical mobility, impaired: False Pain - normal year-old female who presents to the Diabetes Clinic with a new. Mrs. Stukes's husband is not willing to help assist pt upon d/c w/ her stoma care for failed laparoscopic cholecystectomy. - Neurological - increased Instruct Lucy to assist in maintaining pt position and field sterility ambulate 10 days later, Mr. Wright's wounds are healing, and you have orders to prepare for d/c w/ home healthcare. Therapeutic communication Psychological Needs - increased Psychological Needs - normal Explain to the pt. Pain - normal Order a new clear liquid diet Scenario #4 John Duncan Room 302 Joyce Workman Room 303 Meds for new dx diabetes? Sleep deprivation: False Pain: Increased acuity Impaired mobility: True Begin post-op Review medication Ask the pt. 2-Stop the infusion Assess Ms. Horton's orientation -RRT has arrived, coordinate patient care for a stat VQ scan Full assessment Allow family to remain Perform dressing Acute pain Complete neuro Wash hands upon entering the room Pain - normal Marcella Como 18. . Wash & glove Monitor for adverse Anxiety False Prepare and administer Scenario 3 Provide another You return to the pts room 20 minutes later and the pt is pale, lying in bed, feels lightheaded and nauseated when he sits up. Attempt to orient Scenario #2 Recheck Tilts Fall Risk - normal Deficient fluid volume, risk for 3-Notify the physician that the patient may be suffering from alcohol withdrawal. Hypothermia: False Impaired verbal communication, Scenario #1 Ensure there is a full Scenario #3 Have secretary Asses pt. Disturbed body image: False Provide a diversional Scenario 5 Health Change: Increased acuity Ms. Rails states that she has not had a bowel movement (BM) in the past two days. Scenario 5 Have a 2nd licensed nurse Impaired skin integrity: False The CNA reports the blood pressure was 130/86 an hour ago New-patients-swift-river-med-surg-covid-new-patients-charlie-raymond Perform initial assessment Assess understanding through teach back Scenario 4 Tell the mother that you understand Instruct pt. 2-Tell the patient that it has come back, and his Provider will discuss the findings Ms. Barkley continues to deteriorate and is shouting for her family. Start O2 -Blood Cultures - Bleeding, risk for Notify physician Document results Psychological Needs: Increased acuity - Sensorium - normal, - Fatigue Should I be concerned about having sex w/ him? Pain - increased Health Change - increased 1 Administer a mini-mental state exam Impaired comfort Social isolation, Scenario #1 Notify family Fall, for Risk: False Check placement Nausea: False Started on Atenolol 50mg, 1x/day. Continue medicating What is going on? Adjust crutches Scenario 3 Several hours later, Mrs. Hatcher is feeling much better. Call the physician Nausea: False Scenario #4 Dietary consult, Educational - increased Adjust crutches Scenario #2 - Disturbed body image, Scenario #1 Chronic sorrow: False What should be included in the A. Scenario #4 Bleeding: False You tell the pt you will be glad to check-on what is available for relief of his "heartburn" after you complete his physical assessment. Scenario 2 Instruct Lucy Scenario #3 Scenario 3 -Assess radial and apical pulse for 60 seconds Ms. Cumble is in bed and appears comfortable and requests assistance from you to get out of bed to go to the bathroom Obtain doppler pulse Sensorium - normal, Impaired coping Wash and glove hands Complete full assessment Ensure continuous EKG monitoring Visual asess Provide for physical -If concerned about the accuracy, take BP with a manual cuff Insert Foley catheter according to hospital recommended guidelines, to ensure sterility of catheter. Fluid & electrolyte imbalance, risk for Peripheral neurovascular dysfunction, risk for river part Answers to the questions - Estelle Hatcher, 31yr - Studocu Assist Ms. Horton Mr. Richardson is now pain free and questioning why he is plagued w/ recurring urinary stones. Imbalance nutrition: True Request the uncle come You enter room and find Ms. Gestalt crying because she has just learned her medical insurance has lapsed and she is already two months behind on her car payments. Re-apply new sterile dressing. Validate NPO Scenario #3 Fall Risk: Increased acuity After 3 hours Ms. Monson is now crying asking to be released from these restraints and for someone to take her home. Day 2 SBAR 3 vClinical - S Name: Joyce Workman ituation B Full assessment 4-Orient arriving family member to the situation, and explain importance of remaining with the patient Disturbed body: False Scenario #5 Thanks! Tell the pt. Inform his partner that everything is being done to keep him comfortable. Pale pt. Neurological - increased, Acute pain d/c home 2.) Dotty Hamilton Room 301 Dotty Hamilton 52 y/o female who has been admitted for bariatric surgery. Notify doctor Provide pt post MI education of the plan -Put tray on bedside table and align to a comfortable eating position Elevate HOB Educate pt. Call respiratory therapy Reassure the pt. Sensorium: Normal acuity, Physiological - Linda Yu, was admitted to your unit after surgery on her left hip due to a fall. Evaluate the following expression containing percent. Measure wound size at greatest length, width and depth using a disposable paper tape measure. He is still unresponsive. -She experienced life threatening wounds with 2 gunshot wounds, including one to the shoulder Kenny Barrett, 64 years old, was admitted for observation of initial administering of BP his treatment with blood pressure of 220/124 after visiting his doctor for a routine physical. Assess pt's LOC Accompany pt. -Note that the family member support has been invaluable, and encourage her to stay. Provide pt. Ask Mrs. Workman for 24-hour diet Both RN have donned appropriate PPE and have entered the room. Scenario 2 change diet to HH 6.) -Provide mask for patient CPK Call for crash cart He has been readmitted for a red spot on his sacrum of 1 cm and a 2 cm blister on his right heel. Neurological: Normal acuity Administer IV ABX Disturbed sensory perception: True Reassure pt. She appears short of breath when talking. - Acute confusion Risk for post traumatic stress syndrome Imbalanced Nutrition: False Notify Dr Impaired mobility, risk for His partner is not with him at this time but will arrive soon to facilitate his discharge home. Scenario #4 Fear Deficient Knowledge: True Contact chaplain Scenario 4 I am concerned, about keto-acidosis and the complications of, hyperglycemia. Impaired Physical Mobility: True Safety- Administer oxygen therapy to make sure oxygen saturation is greater than 90% Instruct pt not to get out of bed w/o assistance Safety- Explain procedure Document Knowledge deficit: False Use therapeutic - Readiness for self-care enhancement Scenario #5 Scenario 1 Complete full assessment Evaluate/modify. Contact nursing supervisor Risk for constipation: False Scenario #4 - Grieving Decreased cardio tissue perfusion: False Linda Pittmon Room 304 Glucose level? Document process Safety- Scenario 2 -Reapply Silvadene and sterile dressings. Joyce Workman Scenario 1 Mrs. Workman presented to the diabetes clinic and provided a 24-hour food recall. Scenario #5 Impaired home maintenance management: False Deficient diversional activity: False Encourage fluids/fiber/ambulation 2-Have nursing staff introduce themselves and explain their role upon entering the room Fall, risk for Decreased cardiac/perfusion: False Scenario 3 Auscultate lungs Decisional comfort Deficient Knowledge: True Now, third day post-op, Mrs. Stukes appears sad and depressed upon entering the room Pain - increased Evaluate learning Give pt. Educate pt Full assessment Hand hygiene -Review of body systems and evaluate pain on a scale of 1-10 Check I/O for possible dehydration Bleeding, risk for: False Risk for injury: True, Scenario 1 Use therapeutic Report this activity, Bleeding, risk for Fear: True Mr. Raymond weighs 260 lbs. 4-Provide necessary equipment Julia Monroe - Health Change - increased Remove infiltrated IV Have IV abx amiable to administer when surgery calls for the pt to be transferred to pre op area. Scenario #6 Put an arm band Encourage use of IS Fall, Risk for: True. Non-significant past medical history. Scenario 4 Therapeutic communication Obtain 16 gauge angiocath Encourage Mr. Jones Ask the pt if she has had the procedures previously Administer levofloxacin as ordered Allow for non-compliance Vital signs are Temp 98.9F, BP 178/90, P 88, RR 18 SaO2 95% on Room air. Scenario #5 Give IV morphine Explain to her family Fall Risk - increased Notify charge nurse Scenario #3 Full assessment Documentation Fall Risk: Increased acuity Scenario 5 & husband Scenario #4 Request CNA to remain w/ pt When help arrives, pass off chest compressions and begin respiration's Neurological - normal, Scenario #1 She is oriented x3 but at times seems to be talking to someone in the room when no one is present. The CODE-blue team arrives w/ a crash cart, Physician, anesthetist, and 2 critical-care nurses and 1 respiratory therapist. Pain Level: Normal acuity Ms. Hatcher is second day post-op and has a NG tube set to gravity drainage only. Concepts of Nursing IV 80% (5) Request possible change VS reassessment Wash hands & assess Scenario #5 Provide the pt. Social isolation, Risk for: True, Educational Needs: Increased acuity After your AM assessment, the pt's call light goes on and she is complaining of nause, abd pain, and seeing "yellow circles". Nausea Joyce Workman Room 301. Document results and findings Assess for pain Assess last medication Sleep deprivation: False 8 hrs later, pt is fidgety and is observed picking at her skin and clothes. Hopelessness: False. As you enter the room, Mr. Duncan is refusing to eat foods from bland diet Fall, Risk for: False Medicate pt. Stay w/ pt for surgeon's arrival to explain intended surgical procedure. Use therapeutic communication/active listening Are you okay?" - Powerlessness Orient pt. Obtain & verify Inspect cast site Scenario #3 Check I&O Chronic pain: True Record I/O Ineffective Airway Clearance: False : an American History, Physio Ex Exercise 8 Activity 3 - Assessing Pepsin Digestion of Proteins, Lesson 8 Faults, Plate Boundaries, and Earthquakes, EES 150 Lesson 2 Our Restless Planet Structure, Energy, & Change, Assignment Unit 8 - Selection of my best coursework, Logica proposicional ejercicios resueltos, Chapter 01 - Fundamentals of Nursing 9th edition - test bank, Focused Exam Alcohol Use Disorder Completed Shadow Health, Tina Jones Heent Interview Completed Shadow Health 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. Stop infusion Pain Level: Normal acuity Restart pt's IV She is experiencing polyphagia and polydipsia with blurred vision Health Change - increased Ensure pt. Scenario #2 Document conversation Observe & mark 5 Notify HCP of suspected abuse Scenario 5 Have daughter stay, Educational - increased Notify the HCP Pt has a hx of COPD, HTN, DM II, and a recent MI. Safety: Increased acuity, Physiological- Obtaintelemetry Document on the MAR and education in the chart. Neurological - increased Connect pt. Evaluate understanding Marcella Como is now more talkative and shares with you that she is going to cooperate and wants to press charges against the assailant. LOC - normal Apply oxygen Right after admission the nurse finds her walking down the hall trying to leave. Scenario 4 She is requesting the names and home phone number for the wound care nurse who saw Mrs. Stukes while she was an inpatient. Fall Risk - increased Scenario 3 Bleeding, risk for Scenario #5 Ask parents Fall Risk: Increased acuity Educational needs: Increased acuity Psychological Needs: Normal acuity Seek clarification Glucose regulation Document Initial assessment Document, Educational - increased If pt. Her chart reports she was exhibited upon arrival to the recovery area, received three units (3000 mL) of fluid, receiving O2 @ 4LNC, F/C in place draining QS clear yellow urine, responds to verbal stimuli, chest dressing in place remains dry and intact, and has just received a small dose of IV morphine for pain. She was admitted yesterday for stabilization of her glucose levels and . why he will Pt. Remain with pt. Patient has been complaining of a headache and dizziness. Obtain informed consent Document findings Ineffective breathing pattern: True Health Change: Increased acuity Notify Dr. of change Deficient knowledge: True Vital sign assessment of need Use therapeutic communication/active listening Sensorium - normal, Deficient fluid volume Reassure patient of options Fear/Anxiety: True. Document rhythm Scenario 3 Fall Risk - normal Swift R clinicals. Tissue integrity Esteem- Perform admission Take VS now and Q4 hrs Allow visitors to enter, Educational - increased Have an aide sit w/ Ms. Barkley while you obtain the IV supplies and notify the HCP of her declining condition.
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