Tube Feeding: Type:_________________________ Amount/Rate: ________________________ Bolus/Infusion Vital signs -Temp 98.4, BP 116/76, P 96, RR 20, SaO2 99%. Deficient Knowledge False -Determine when a hospital provided sitter will be necessary Scenario 1 GI WNL. Scenario 4 Sitting, BP 109/60, P 114, Standing the patient becomes very lightheaded and the nurse has them lay back down. The nurse identifies self to the nurse triaging patients and is directed to trauma room 4. Fear True 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. D/C plan- decrease pain and restore normal gait. Scenario 2 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. -Assess patient's understanding of the teaching and discuss home support, os de la main et de la ceinture pelvienne, Julie S Snyder, Linda Lilley, Shelly Collins. You discuss this cough with Mr. Dominec to determine how long he has had it. Document results Vital signs -Temp 99.1, BP 124/62, P 77, RR 20, SaO2 91%. Educate patient Scenario 2 Scenario 1 Love and Belonging Obtain urinary screen Vital assessment No known allergies. You have them remain with you, seated in comfortable place, while you call ICU and attempt to locate physician for them. Water/Flush: Pain re-assessment Genitalia: WNL (skin intact, no lesions) Abnormalities Describe: __________________________ Rapid Response team arrived including anesthesia. Perform circulatory evaluation Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 97%. Remain with patient and reassure jasmine . -Explain that Docetaxel is a hormone therapy that suppresses the testosterone that your testicles produce producing similar results as surgical intervention. Bleeding: True Scenario 4 Mrs. Pittmon states she has had numbness for years but "now I can't . -Reapply the NC that he was admitted with at 2L Assessment of bowel movement No known allergies (NKA). Ineffective Self-Health Management False Palliative care. Scenario 2 Wound clean dry and intact. Ms. Gestalt capillary refilling is now 6 secs below cast site, extremity is swollen and cold to the touch. VS: BP 158/90, HR 89, R 18, T 97.8 F. Provide emesis basin/cloth August 13, 2020 // by Angela McGowan. Scenario 2 Scenario 5 Vital Assessment Safety Electrolyte Imbalance False Mr. Thomason is anxious and is obviously worsened from the shift before in overall condition. Mr. Greer has just been visited by his wife. She is with her physician. Senario 4 Extends abnormally = 2 Verbal response Oriented converses = 5 Pregnancy and labor and delivery are not typically associated with the concept of cellular regulation, Patient: Donald Lyles,52-year old male, was admitted yesterday evening for stabilization of his uncontrolled type II diabetes. Roger Clinton, 57-year-old male construction worker arrives at 0600 to be prepared for a partial thyroidectomy to determine if he has cancer. Where is my camera man!! Start secondary large bore IV line Scenario 3 He has a history of well controlled GERD with over-the-counter Tagamet (Cimetidine), and Tums. Document results and findings Use therapeutic communication/Active Listening Health Change Increased acuity In reassessing Ms. Monson, her vital signs are: BP -106/82, Temp-98.2, P-106, RR-18, SaO2-88. Diet as tolerated. Document results Scenario 4 -Ensure IV is patent, Lithia Monson Obtain patient record and follow patient as he is transferred to ICU Peripheral Neurovascular Dysfunction False Filmotka filmu Najvyia ponuka (2013). Senario 2 Vital signs -Temp 98.6, BP 114/62, P 100, RR 20, SaO2 94%. Senario 5 Social worker with patient this morning. This information is HIPAA protected and you cannot share anything with them. Scenario 2 Mr. Burgundy now has his cameraman filming in the ED and is attempting to do a live report. No known allergies (NKA). , a 58-year-old male patient presents to the ER CO CP 10/10. Swift River Medical-Surgical. Impaired Gas Exchange True Severe pain (10/10) medicated q 30 minutes x4 with IV Morphine 2mg with little relief. Notify doctor Shock False Fall, risk for True Assess for fall risk Reasses temp in 1 hour. Contact charge nurse. Evaluate learning Dr. Small at bedside with patient and family. Recent chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes. Ms. Getts is now complaining of sudden sharp, substernal chest pain, very short of breath and is profusely diaphoretic. Localizes pain = 5 Pain Level: Increased acuity Report current urinary output quantify per hour and color of urine Infection, risk for: False. Temp 98, BP 114/67, P 115, RR 20, SaO2 98%. -Explain procedure to the patient No known allergies (NKA). Ms. Cumble states that she has not had a BM for three days. RS Vclinical Flowsheet - Student Name : Date: NUR 113 Assessment Swift Place call light and check bed for safety Fall Risk Increased acuity Grieving: False. The bed arrives tomorrow. 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. swift river assignment: day swift river assignments dosage minimum score 90 med minimum score 80 minimum score 90 robert sturgess linda yu linda pittmon carlos Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions Keiser University Silver Creek High School (Colorado) Vital signs -Temp 98.4,BP 178/105, P 112, RR 28, SaO2 94%; Neuro- WNL's. Ms. Gestalt is second day post-op and has requested to get out of bed and to ambulate to bathroom. Senario 3 : an American History (Eric Foner), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Combien gagne t il d argent ? Imbalanced Nutrition True Assess toe movement and capillary refilling Blood Pressure, 7a-7p Total: 7p-7a Total: Her husband and children remain with her in the surgical holding area awaiting transport to the OR. After two hours, Mr. Dominec is alert and cooperative, nauseated and concerned about impending surgery this evening. Make-Up Clinic Day 3 MS - Swift River Assignment: Make-up Day 3 Swift Skin warm and dry, all vital signs in WNL except 115 pulse, which is normal for him. Background Robert Sturgess the client was admitted with Metastatic cancer of Colon, with history of diabetes. -Begin q15 minute neuro checks Biopsies were sent to determine the treatment. IV maintenance fluids with D5 1/4 NS @ 150 ml/hr X 3 then reduce rate to 75 ml/hr. He is aware that he may not have an erection and may need depends for bladder incontinence. Sensorium Normal acuity, Physiological Scenario 5 Airborne Isolation. -Medicate for pain He is restless with slight confusion but is easily orientated with attempts from nurse. Chronic Pain True 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. -Continue to observe urine for hematuria and document findings Scenario 2 Impaired Mobility, Risk for True Request sitter/family member to bedside Educate patient regarding patient care -Assess if the contents of lunch tray are intact. Discuss his understanding about the plan of care. Sarah Getts Scenario 1 Glasgow Coma Scale 0-15 Musculoskeletal -Ensure patients is positioned in bed properly Pulses: Strength & Symmetry Edema: Awaiting transport. Oral Care 97.4, Resp 16 and Pulse Ox 94%. Expresses fatigue, fear, concern, and desire for recovery. Administer antipyretic medication Educate patient Neuro WNL's, alert and cooperative. school system of the host country and may not know how to choose the programme, Question 34 Correct Mark 100 out of 100 Flag question Question text hr tag, efefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefefef, arbitrary parameters a b will be a complete solution of 38 The main problem then, Reduces costs of providing on site office space To individual Makes more time, METHYLXANTHINE DRUGS-Chemistry FinalsExam PrepNotes.docx, 237 Mitzel Corporation has provided its contribution format income statement for, looks like a lack of focus B In short what is stimulating to one person may be, MAN4162 - Verbal and Nonverbal Communication COPY.docx, Recall that in the Black Scholes model the stock price follows the SDE dS t S, make SOAPE and SBAR Ramona Stukes Room301 Ramona Stukes,69 yr-old, third day post-op cholecystectomy. Fear True Scenario 4 Swift River_2020 | NURS 320 Med_Surg_Swift_River_Graded A - Qwivy This will treat any cancer that may have metastasized to the bone. Listen to patient concerns Notify Doctor for pain medz and the GI cocktail given in the ER did relieve his CP but not completely. Scenario 5 Your notice Mr. Thomason is lying supine, appears slightly cyanotic in his lips, is exhibiting more effort to breathe, and is increasingly restless. It is unclear if he lost consciousness. Teach patient about safety when getting out of bed Notify lead nurse/doctor -Advise patient not to get up and walk on his own DSD (dry sterile dressing), forehead laceration clean and dry intact. LOC Normal acuity Scenario 4 Provide information for MD to call family at home and explain what has just happened Color:__________ His left humerus is fractured and splinted. High fall risk. Scenario 4 Skin cool to touch and appears pale. -Provide the patient with the time when HCP will come discuss options with him -Inform patient to not get out of bed without assistance and place call light in reach Grieving False Ronald Burgundy Provide for physical and thermal comfort. Impaired Skin Integrity, Risk for False The provider advises the Nurse to draw a stat CBC, give a liter bolus of NS, and repeat CBC. 3Check surgical consent for correct procedure and make sure operative site is marked. Recently he manifested an unusual black lesion on his thigh and developed an opportunistic fungal mouth infection which was treated successfully. Hopelessness True Increased fall risk. Acute Pain True Document results Notify doctor Breath Sounds: Clear bilaterally. Ms. Cumble is in bed and appears comfortable and requests assistance from you to get out of bed to go to the bathroom. Ineffective Renal Perfusion, Risk for True The patient is asking you where her son is, the last place she saw him was right before the explosion. Mr. Sturgess does not have a living will or durable power of care completed. Sexuality: True. Carotid:____ + Bilateral Other: _____________ RUE: Non-pitting Pitting ___+ Perform neuro assess Spanish interpreter available at extension 61178. Neptune is an average distance of 4.5109km4.5 \times 10^{9} \mathrm{km}4.5109km from the Sun. Remain with patient Senario 2 Offer nutrition/toilet 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. 50% intake. Use therapeutic communication/Active Listening Obtain and provide the infectious disease doctor's contact information for him. Wash and glove hands The nurse arrives and sees a tent is being erected as a triage area, and ambulances are lined up delivering trauma patients. Respiratory Assessment Explain that he will probably not be going home at least until his doctor sees him. Health Change: Increased acuity Discharge instructions Patient and family upset regarding dx. Educate patient/family Senario 5 Noncompliance: False -Complete full assessment, to include neuro You take his vital signs which are: Temp 101.3, Pulse 88, Resp 24, B/P 116/84. ASA is held but morphine 4 mg was given after his GI cocktail. You are now preparing for discharge, place steps in order: Senario 1 No Known allergies (NKA). Reassure patient and help explain any new orders from physician to patient ExplanationAnxiety/ fear True Fall, Risk for True Senario 3 -Reassess patient's physical status prior to leaving him in the hallway Dr. Levine, Marcella Como, 38 yr-old, Sexual Trauma Victim (Rape), unknown assailant. She has been documented as being obese, new onset. Scenario 2 Respiratory Rhythm: Regular Rhythmic Irregular Periods of Apnea Cheyne-Stokes Scenario 3 Scenario 5 Too bad the cruise area was a very unatractive part of the River Elbe. Administer antipyretic medication Safety- Report to charge nurse/ head nurse the need for staff education. Full assessment including both lying/standing -Ensure bed is in lowest position, and rails are in place -Ensure patient privacy and call for help and assist patient to bed once help arrives Identify patient RLE: ______________ LLE: _____________ Students will form a preliminary assessment based on reported assessment data for medical surgical patients in a virtual clinical environment. To access your Swift River Virtual Clinicals login to ATI's Student Portal and access the Virtual Clinical card in My ATI. Ineffective Airway Clearance True Stay with patient for surgeon's arrival to explain intended surgical procedure Scenario 3 Scenario 5 Scenario 4 Wash and glove hands Scenario 3 Perform pain re-assessment Vital assessment Pain Level Increased acuity Social Isolation, Risk for True As you enter the room, Mr. Duncan is refusing to eat foods from bland diet. -Check patency of Foley catheter, urine color, and ensure it is secure to the patient's leg 20 ga. Hep-Lock in right forearm, skin warm and dry, generalized weakness with recent weight loss. Failure to Thrive: True. Assign nursing diagnosis and plan the appropriate intervention and evaluate outcomes while working through time pressure and distractions, including random call light requests. Spiritual Distress False. Non-significant past medical history. Pupils: PERRLA Size: R: mm L: _mm Unequal Sluggish Non-reactive Heterotrophs include (1) autotrophs, saprophytes, and herbivores (2) omnivores, carnivores, and autotrophs (3) saprophytes, herbivores, and carnivores (4) herbivores, autotrophs, and omnivores. Administer protocol antidiarrheal medication Noncompliance True. -Assess patient's ABC (airway, breathing, circulation) Offer nutrition and/ or toileting -Discuss effectiveness of sitter 45 terms. Flexes abnormally = 3 Surrounding skin: Moist/Intact Red/Erythema Irritation Mr. Wright is pleasant and cooperative, but needs to be reminded to avoid pressure on his heel and sacrum. 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. He requests no visitors at this time, but later asks for his family to be called to discuss a plan of care. Welcome [evolutionmkt.co.za] His difficulty voiding finally motivated him to seek care. Physiological Combien gagne t il d argent ? 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. She has been admitted to the floor with complaints of numbness in her right foot and ankle. Hypothermia False Provide comfort in pre-surgical room Mr. Dominec. Exam January 9 Spring 2020, questions - Studocu Respiratory Effort: Relaxed, Regular, Non-labored Pursed lip breathing Labored Call rapid response Health Change Increased acuity Electrolyte Imbalance, Risk for True Provide emotional support. Esteem 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. Reorient Patient to person, place, & time Impaired Home Maintenance Management False Next time we'll spend our 60 on some food and nice beers. Stools are decreasing but patient remains very weak. Dr. Anderson, Educational Needs Increased acuity LOC Normal acuity Remind staff that Universal Precautions are practiced at this hospital for all patients regardless of known infectious diseases. Verify call light/bed safety precautions Lithia Monson Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. -Perform neuro assess 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". Psychological Needs Normal acuity No Known allergies (NKA). NG tube to low suction possibly D/C'd today after Dr. Levine rounds. Demerol 25mg SIVP for pain, patient reports 7/10 on pain scale. If family/visitors come, will need education to airborne precautions. Robert Sturgess Scenario 1 Mr. Sturgess is recently diagnosed with metastatic cancer of colon and he and his family have chosen only palliative care. Vital Signs: B: 160/92, P: 96, R: 22, SpO2: 98, T: 98.9F, 37.1C. Scenario 2 RLE: ______________ LLE: ______________, Casts/Splits: ____________________________, Motor response Verbal command = 6 The Elbe River - hamburg.com A special lowbed has been ordered that will lower to the ground. Ms. Gestalt is now complaining of fever and chills. Esteem Disturbed Body Image True Scenario 5 Perform circulatory evaluation Robert Sturgess - Swift River - Robert Sturgess Educational needs Evaluate understanding -Complete secondary assessment once the patient is in bed focusing on complaint of pain resulting from the fall Chronic Sorrow False Assume role in response team of documenter Scenario 5 Genitourinary Assessment No Known allergies (NKA). Skin integrity, impaired True Scenario 1 Scenario 2 Pain Level Increased acuity Evaluate understanding Palliative care. Peripheral Neurovascular Dysfunction False. Pain Level Increased acuity Some hair on the left side of his head has been burned off, as well. Notify housekeeping. You return to the break room on your floor. The patient describes this pain as a heavy pressure with intermittent stabbing. Pain: No Yes: Location: ______________________ Acute Chronic Constant Intermittent You escort them with you to the ICU. DOCX Swift River Online Learning - Taxonomy 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. Robert Sturgess Scenarios Swift River.docx - Course Hero He is experiencing new onset of shortness of breath and has a nasal cannula with 2L of Oxygen in place. You arrive in room to find Ms. Monson talking to herself. Check pedal capillary refill Scenario 1 Wash hands Pain, Acute True Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Deficient knowledge: True Safety Document results Senario 3 Determine from medical record if partner is aware of his recent AIDS diagnosis. Full assessment The patient was placed on 2 L O2 NC, EKG monitoring to include a 12 lead, Pulse Oximeter. Notify doctor if condition is abnormal Remind the nursing staff that the patient is NPO. Acute Pain False Mr. Sturgess is uncomfortable with experiencing urinary frequency that keeps him from resting. Monitor and evaluate fluid intake Full assessment You call his doctor to inform him the family has arrived. What order are you providing the information to the receiving nurse? -Evaluate patient's understanding of teaching Sensorium: Normal acuity, Bleeding, risk for: False He told the nurse that he has had some changes in his bowel habits and his stools have been very dark. 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. Scenario 1 His CP is 7/10 and his BP is 165/96, P 92, R 18, SaO2 98 on 2L NC. Scenario 3 Noncompliance True Provide Operative summary of type of procedure, IV fluid and pain status. Assess for bowel sounds IV NS is started, and lab work is sent. Upon entering room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." . Self-Care Deficit False Regardez le Salaire Mensuel de Nba 2k23 Pc Review en temps rel. Love and belonging Obtain vital signs machine Yes Check PRN pain order Impaired skin integrity: False, Anxiety: True Continue.Robert Sturgess Room 305 Robert Sturgess, 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. You enter his room and recognize that Mr. Thomason appears to be talking to himself and appears confused. Paul Greer He also states he is feeling weak. Skin warm and dry, all vital signs in WNL Dr. Rondeau, Educational Needs Increased acuity Request time she can arrive and staff to help with transfer Mr. Greer has just returned from surgery. Until the recent diagnosis of cancer, the patient had only seen a physician once in the last ten years. She is having some difficulty breathing. Love and belonging Dysfunctional Gastrointestinal Motility False Neuro WNL alert and cooperative. Fall, Risk for True Mr. Greer is on the floor still but is awake and oriented and is complaining of back pain below his right scapula. Document results and findings Educate about recovery from appendectomy and care to wound. -Check on patient/sitter hourly Scenario 1 Acquire daily weight and food intake Scenario 5 Talk with her stating surgery is over and she did great. Procedure is canceled for the day and rescheduled later allowing for new consent. Dyspnea at rest Dyspnea with minimal activity Use of accessory muscles Scenario 2 Vital signs are to be taken BID, and it is now time. Safety- -Ask the patient if it is okay to discuss his care in front of his children. Bleeding, Risk for False Seek clarification He has not had his BP medication today. Patient and family upset regarding dx. Neuro WNL, alert, and cooperative but worried about scarring and is reluctance regarding walking on leg. -Transport Mr. Burgundy to his room Disturbed Sensory Perception False No Known allergies (NKA). Apical Pulse Rate: Heart Sounds: Normal S 1 S 2 S 3 Upon entering room, you wash/glove hands. Ruth Cummings - The Nathan Cummings Foundation Compromised Family Coping False Scenario 5 Alleviating Factors: Last pain medication: Scenario 2 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. Verbal command = 3 **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 (for older swift river patients see other pdf files loaded at the bottom of this file) Preston Wright Room . Use therapeutic communication/active listening Notify doctor of change in condition in particular: unproductive cough and low-grade fever. Fatigue True -Give NS liter bolus Love and belonging- Regardez le Salaire Mensuel de Tthuchicago Org en temps rel. List of American films of 2008 - Wikipedia Safety Assess for bowel sounds Educate patient How does the Med-surg simulator work? Safety No known allergies (NKA). Raspberry and Cream Cheese Stuffed Blueberry French Toast with Ozery. He has a history of hypertension and is not compliant with medication. Urinary Catheter: N/A Indwelling Short-term Indwelling Long-term Date of Insertion:________ Size: _____F Purposive Communication Module 2, Chapter 1 - Summary Give Me Liberty! Deficient knowledge: False Decreased Cardiac/perfusion False How was this river part Answers to the questions; Fillable SOC 1 DLA 1; Fillable SOC 1 DLA 2 - Notes on Environmental effects through sociology . -Reassure patient that he will be moved to a private room as soon as possible Apply oxygen Mr. Mancia's vital signs upon assessment are Temp 101.2, P 94, RR 20, BP 122/82, SaO2-91%. The pain makes him short of breath. Report and document results Grieving: True 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. Your Swift River Virtual Clinicals account has been linked to your ATI Student account. Evaluate caller understanding Powerlessness True. Evaluate outcome of dietary plan Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma.