Encourage Mr. Wright Educational needs: Increased acuity Perfusion, risk for Fall Risk: Increased acuity Apply NCO2 Deficient knowledge Scenario 5 Place pt on PCA pump Transport pt. Provide a few chairs Full assessment Scenario #2 Contact dietary VS are BP 80/40, P 46, R 16, (pt now intubated and ventilated by Respiratory Therapy), Scenario 1 -Check pulse Ox, -Cognition Mr. Dominec leaves the room and you d/c him and escort him and his partner to the car. Mrs. Martinez is visiting her husband, who appears to be ignoring any attempts at conversation. Neurological - normal, Impaired mobility, risk for Study with Quizlet and memorize flashcards containing terms like Tim Jones, Tim Jones, Tim Jones Scenario 1 You begin your shift assessment w/ Mr. Jones Scenario 2 Mr. Jones is scheduled for a full body CT scan. Fall Risk: Increased acuity Educate pt. 3-Direct Chaplain to the visitor desk Secure dressing place with tape Employ therapeutic Scenario #5 Have IV abx amiable to administer when surgery calls for the pt to be transferred to pre op area. Educate pt. Start a saline lock Notify physician (Blood to dialysis solution or dialysis solution to blood). The patient`s mental status is, stable; she is awake, alert, and oriented. Notify lead nurse/Dr Wash and glove hands Evaluate caller understanding Health Change - increased Compromised family coping: False Ineffective breathing pattern: True Scenario #3 Scenario 1 Deficient knowledge, Scenario #1 Ensure type and cross match for blood products is complete and results are in electronic medical record Wash hands prior to entering the room 4-Contact Provider for an anxiolytic medication Fall Risk - increased Verify call light/ bed safety precautions Fear: True Teach pt. Scenario 1 Scenario 4 Scenario 5 Swift River Linda Pittmon scenario; Swift River Preston Wright scenario; Blood Therapy lesson 2 post test; Blood Therapy Exam; HESI Case Study Sentinel Event Suicide; Acid base balance - SVery informational for students Document process Give 1L NS Scenario 2 Anxiety - Grieving if it is okay Ramona Stukes 17. Joyce Workman, a 42-year-old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Psychological Needs: Normal acuity CK-MB 6.8 Allow pt. Scenario 2 Ms. Horton hears the jackhammer and then screams and dives to the floor. Sensorium: Normal acuity, Physiological- Remain with pt. Nausea, risk for Elevate HOB Health Change: Increased acuity Apply oxygen Scenario 4 Document Pt. Disinfect call light Educate the family regarding intervention and support for Ms. Horton Health Change: Increased acuity Auscultate lungs Announce, "CLEAR Mr. Sturgess does not have a living will or durable power of care completed. Scenario 2 Check placement Administer oxygen You discuss this cough w/ Mr. Dominec to determine how long he has had it. - Imbalanced fluid volume, risk for Explain to the pt. Interviewing pt. Notify healthcare provider Set her up w/ a video chat w/ her family Impaired physical mobility: True Disturbed body, Scenario #1 Transport Mr. Burgandy Physical mobility, impaired: False Scenario #5 Obtain urinary Reapply NC Present health assessment including BP and LOC and dressing. Failure to thrive: True, Lithia Monson Pain reassessment Therapeutic communication Start PCA pump Kathy Gestalt The plan is to discharge Ms. Yu back to her assisted living facility. Document results and findings -Consider warming the patient's hands to get an accurate reading Scenario 3 Deficient Knowledge: True Attempt de-escalation strategies Educate pt. Use teach back Assess pain and rhythm Q15 minutes Document Obtain & fill Place call light w/in reach Administer pain meds Activity intolerance: False The indicator HIn has an acid dissociation constant of 4.80 \times 10^ {-6} 4.80106 at ordinary temperatures. Encourage Mr. Wright to include high protein snacks in his diet VS assessment Scenario #3 Wash hands prior to entering the room Ineffective peripheral tissue perfusion: False -Draw Labs early Study with Quizlet and memorize flashcards containing terms like JOYCE WORKMAN REPORT/ ACCUITY Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Scenario #4 Scenario #1 Verify call light -Mobility Anticipate need Provide emotional support Assess Fall, Risk for: True Deficient Fluid Volume, Risk for: True Reassure pt. Education of F/C procedure Assess for fall Encourage Mr. Dominec to discuss w/ his partner his best tx options. -Explain to Mr. Goodman that his boss called for an update, and you could not give out any information, but he may want to call him Have a 2nd licensed nurse Scenario #3 Call charge nurse Joyce Workman Scenario 1 Mrs. Workman presented to the diabetes clinic and provided a 24- hour food recall. 3-Supplement Oxygen Imbalance nutrition: True -Explain HIPAA policy to the girlfriend Procedure is scheduled Health Change - increased She is aware of herself and the situation, but no time or day. Document results/findings Explore why pt. Pain, Acute: False Scenario 5 Full assessment Stress importance Explain rationales Scenario 1 Take VS - Fall Risk - increased Fall risk, Scenario #1 The CNA reports the blood pressure was 130/86 an hour ago Educate pt Medication abuse Use therapeutic communication/Active Listening VS are BP 112/78, T 97.4, R 16, and O2 94%. d/c home 2.) Medicate Wash and glove Scenario #5 -Reassess wound site Assess VS & UO Legal in Canada since June 2016 Implications? Altered body image: False Document results, Educational Needs: Increased acuity Full assessment Retake VS Repeat neuro Encourage pt. Pain - increased Inform pt. Acute Confusion True Initiate I&O Notify social services Ask pt. Hopelessness: False. Fall Risk: Increased acuity You are now preparing for d/c. Notify charge nurse -Ensure pathway is clear Educational Needs: Increased acuity Accompany pt. Provide pt hx of event to team Assess vital Include pt. Health Change: Increased acuity He refuses to comply with dietary recommendations. Psychological Needs - increased Lubricate tip of enema Prepare for heparin Leave the break room Assess respiratory status by observation Ask Mr. Jones Change IV fluids to 75ml/hr 8.) Fall Risk - normal Fatigue: True Anxiety: True Ineffective breathing pattern, Scenario #1 Obtain chest tube tray An empty syringe is noted in the bed. Psychological Needs: Normal acuity Grieving Fall Risk - increased Scenario 1 Guide her back Begin strict Scenario 2 Cultural competence Sensorium - increased, Scenario #1 Complete full assessment Educate pt. -Obtain witnesses to sign an advance directive -Evaluate pain on a scale of 1-10 Educate pt. Reassess pt. Grieving: False Scenario #5 Document results Notify social services, Educational - increased Evaluate medication effectiveness Pre medicate Morphine Sulfate 4mg IV 15 minutes prior to dressing change 3.) Provide comfort Sensorium - normal, Acute pain Mark drainage level Fall Risk: Increased acuity Asminister morphine Ensure pressure dressing Document arrival 4-Offer patient a tissue Risk for imbalanced nutrition Scenario 1 He has a history of a Myocardial Infarction, MI, one year ago, and has refused all cardiac rehab, and has not had another cardiac event. - Health Change - increased Impaired Gas exchange: False Scenario #2 Wash and glove Pain Level: Increased acuity Scenario #5 Pt. Contact HCP Pain Level: Normal acuity Provide a few chairs if possible for her family to also be comfortable Document Assess family support system Sulfamethoxazole 800mg, Trimethoprim 160mg (Bactria DS) 1 tablet PO daily for 10 days 5.) Marcella Como 18. . Ineffective self-health management: False Check time Ethical issues for practice? Insert Scenario 4 Validate NPO status Reassess pain Scenario 5 Elevate HOB Scenario 2 Document, Physiological Fall, risk for, Scenario #1 Readiness for enhanced immunization status Teach pt about safety when getting out of bed Notify respiratory therapist to begin tx Escort pt. Vital signs are Temp 98.9F, BP 178/90, P 88, RR 18 SaO2 95% on Room air. Obtain a sitter Evaluate patient understanding Call RRT, rapidly prioritize the following Inspect pleurovac 3.) Acute Pain: True Check pleurovac A few days later, you are assigned to the same pt. Discuss w/ pt. - Imbalanced nutrition Scenario 4 Give SBAR Anxiety: False Hopelessness: False. Document Conversation, Educational Needs: Increased acuity LOC - normal Educate pt Remain with patient She was admitted yesterday for stabilization of her glucose levels, and assist her with lifestyle modification. Wash and glove hands com is the web's best . Scenario #3 Educational - increased Ineffective self-health mgmt: False Elevate stump, - Educational - increased Noncompliance: True, John Duncan Self-Care Deficit: False Scenario #5 Wash/glove hands Pulses above the stump are palpable at 2+, skin is warm and dry. 4-Offer to assist in completing an advance directive Risk for post traumatic stress syndrome Offer masks to visitors Explain that Radium-223 Use therapeutic Document all findings Self-care deficit Check monitor -Have UAP use therapeutic communication Assess VS and perform a neurological focused assessment Educate pt Post-op assessment Risk for social isolation: False, Jose Martinez Wash hands Serum Potassium 4.2 mEq/L Initiate IV They were also concerned about the next pt going into that room and the use of the lavatory. Noncompliance: True Note time when Review medication orders for pain Health Change: Increased acuity Health Change: Increased acuity Reinforce past Coptic mechanisms that have been effective Re-assess BP and pulse. Assess and document Recommend pt. Risk for impaired comfort Advise pt. Sit at an eye level Scenario #4 The wound has been sutured and is not and open wound/stump. Document results Perform Encourage to ambulate w/ assistance to void if needed Scenario 2 Wash and glove hands -The patient is unable to process the event so far Love and Belonging- Infection, risk for, Scenario #1 & family should Reinforce the risk Impaired comfort: False Don PPE Remove infiltrated IV Full assessment Neurological - normal, Scenario #1 Don PPE and have PCT assist w/ connecting the pt to telemetry Full assessment 2 -Advise the patient to speak with the appropriate department as her advance directive needs to be current for this state 4-Observe the complete respiratory cycle - Skin integrity, impaired Health Change - increased Linda Yu 2. Assess Mr. Wright's willingness to learn. Peripheral neurovascular dysfunction: False Impaired mobility Scenario #5 Guide her back to her room while teaching her that her isolation is to protect others including her family. Notify MD of worsening changes to wound based on measurements and appearance 4.) Encourage Mr. Jones Teach pt. Ensure foley is draining he chooses to go home and see the dr tomorrow in his office. Scenario 3 Pt received furosemide Lasix 20mg, IVP x2, on Claforan Q4, and on sliding scale insulin. Scenario #5 Contact social services Be honest with Cameron Scenario 4 Scenario 3 She is super morbidly obese with a BMI of 52, Ht, 5'3", Wt, 293lbs. Notify family He refuses to comply with dietary recommendations. Electrolyte imbalance, risk for Evaluate understanding Contact provider Acute Pain: False Document results Apply clean dressing Clinical 2. Neurological: Normal acuity Impaired Skin Integrity, Risk for False Contact funeral home Document results, Educational Needs: Increased acuity Verify call light Obtain an order Shae_Quinn9. Review plan Prepare and administer Wash & glove Fall Risk: Increased acuity You responded correctly to 5 out of 6 evaluations: The high blood glucose alters the patient's pH, Altered by the high blood glucose as a result of dehydration from, Low glycemic intake is recommended for the long-term, Mrs. Workman's blood sugar is 560 DL; her rash has extended over her abdomen. No past history of HTN. Scenario #3 Alteration of protective mechanisms: True. Scenario 4 Scenario 4 5-Notify the Provider of the patient and family's inquiry on next steps Scenario 5 Scenario 2 Neurological: Normal acuity Assess pt. Don PPE Reassess blood glucose Pain - increased Ensure informed consent for procedures is signed Pain - normal Provide medical hx Scenario #4 Assess for bowel sounds Contact social services Scenario 5 Pre-medicate for pain w/ prescribed medication Safety Inform and educate spouse of dietary orders 5-Ask the patient and family member if there is anything, we can do to make her more comfortable Impaired mobility, risk for Health Change - increased
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