Dr. Donofrio. When she moves him to the hallway, Mr. Burgundy begins yelling at you "Do you know who I am, I demand a room! Evaluate/modify plan of care Scenario 3 Electrolyte Imbalance False He insists that he is not hungry and refuses assistance with his meal. Educational Needs Increased acuity No known allergies (NKA). Psychological Needs Increased acuity -Complete neuro checks as ordered -Reassure patient that he will be moved to a private room as soon as possible The ER nurse reports that his cardiac enzymes were borderline, (Troponin?, CK/CKMB?) Determine clinical decisions based on listening to an audible client report. 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 -Assess if the contents of lunch tray are intact. Acute Pain True 1. He replies, "six times in the past four hours". Sa fortune s lve 2 000,00 euros mensuels RLQ: RUQ: LUQ: LLQ: You observe Ms. Getts being assisted by another nurse who is being blatantly rude and disrespectful to her. The provider advises the Nurse to draw a stat CBC, give a liter bolus of NS, and repeat CBC. is a 57 y/o who has been admitted for a radical prostatectomy. Full assessment of patient. Compromised Family Coping False DSD (dry sterile dressing), forehead laceration clean and dry intact. Pain Level Increased acuity Scenario 2 Encourage Mr. Dominec to discuss with his partner his best treatment options. The charge nurse tells the nurse to take Mr. Burgundy to the floor, because his room is now ready. Document results and findings Scenario 3 Diet as tolerated. Isolative, appears fearful, crying, and refusing to see her husband. She shares concern about patient's wife who is now coughing and having night sweats. Contact head nurse or supervisor in the OR to evaluate new situation Gown and mask Last Bowel Movement: Date: _____________________ Constipation Diarrhea/Loose Other: -Explain to patient why his throat may be sore -Complete initial post-op assessment Insertion Site: Dry/Intact Redness/Erythema Drainage Tenderness Maceration Safety Administer antipyretic medication As you enter the room, Mr. Duncan is refusing to eat foods from bland diet. Spanish interpreter available at extension 61178. Radial: ____ + Bilateral Other: _____________ RLE: Non-pitting Pitting ___ + -Assess for fall risk Nathaniel Gonzalez -Explain that Docetaxel is a hormone therapy that suppresses the testosterone that your testicles produce producing similar results as surgical intervention. Skin warm and dry, may sit up on edge of bed today. Notify doctor for Foley catheter -Offer nutrition/toilet This will treat any cancer that may have metastasized to the bone. Remind the nursing staff that the patient is NPO. Impaired comfort: True There is an order to apply a waist belt restraint if needed. He also complains that his throat is still very sore. Diet as tolerated, up ad lib after gait training. After washing and gloving hands, you then identify yourself and the patient, Ann Rails. Scenario 5 Document conversation Scenario #3. -Ensure the bed is in lowest position, the side rails are up, the call light is in reach, and ask the patient if they need anything before you leave the room Scenario 5 Scenario 3 Mr. Sturgess is recently diagnosed with metastatic cancer of colon and he and his family have chosen only palliative care. Neuro- confusion to time and place, but oriented to self, speech clear, poor historian, did not recognize son today which is new for her; Neuro assessment and vital signs q1 hr. Employ therapeutic communication: present reality IV NS is started, and lab work is sent. Chronic Pain True Your coworkers are asking you questions about Mr. Dominec. However, he quit three years ago when he remarried; he and his wife have a nine-month-old baby. 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. 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. Acute Confusion False Chronic Pain False Ambulates with assistance. Safety Safety Increased acuity, Physiological Scenario 5 Senario 4 Bladder distention Pelvic pain Low back/flank pain Educate patient regarding condition Pulse Scenario 5 Scenario 1 Document findings/results, Ann Rails, 38 years old, c/o back pain, non-significant past medical history. Scenario 4 PT to educate patient Senario 3 You correctly diagnosed 11 out of 16 options. Senario 1 Due to this, the provider would like him to stay in the hospital for observation. Apply oxygen Impaired home maintenance mgmg r/t client or family: False Anxiety True IV fluids of D5 1/2 NS are infusing at 100 mL/hour to his right forearm. Scenario 1 Acquire daily weight and food intake Respiratory Assessment The patient is asking you where her son is, the last place she saw him was right before the explosion. Your response to all of them would be: Scenario 1 Check monitor Upon entering the room with a translator to admit him to the hospital, he is asked for address and phone number but refuses to comply. Students will form a preliminary assessment based on reported assessment data for medical surgical patients in a virtual clinical environment. Scenario 4 It was diagnosed by a portable X-ray and quickly splinted by the ER staff. Scenario 2 Do not probe further Scenario 1 Document results Ineffective Self-Health Management False Ms. Rails states that she has not had a bowel movement (BM) in the past two days. You have them remain with you, seated in comfortable place, while you call ICU and attempt to locate physician for them. Pain Level Increased acuity Sarah Getts 00 Comments Please sign inor registerto post comments. Filmotka filmu Najvyia ponuka (2013). Psychological Needs Normal acuity Too bad the cruise area was a very unatractive part of the River Elbe. Swift River Medical-Surgical. Upon entering room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." . Senario 4 Full assessment Disoriented to time and place, speech slurred. 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. Alleviating Factors: Last pain medication: Some hair on the left side of his head has been burned off, as well. 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. Arthur Thomason Scenario 2 -Continue to observe urine for hematuria and document findings The patient has a Foley catheter in place and is reporting 8/10 incisional pain and he is asking why his throat is sore. Identify patient Secondary: Assess vital signs, auscultate heart, lungs, and bowl sounds. -Take initial vital signs (room air Pulse Ox) When a physician makes an incision into a body cavity just superior to the diaphragm and inferior to the neck, what body cavity will be exposed? Offer assistance Scenario 5 Temp Perineal Care Document pt's statements. Yes No Contact Social Services RLE: ______________ LLE: _____________ Wound clean dry and intact. Attain fluids/fiber diet and assisted ambulation High fall risk. Blood, Glucose 185, 4 units of insulin sliding scale for coverage. Apical/Radial Pulse Deficit: No Yes Murmur Valve Click Scenario 1 Observe closely first hour Notify lead nurse/doctor -Place patient on O2 Nasal Canula You are concerned about preventing the patient from falling. Imbalanced Fluid Volume, Risk for True Diet as tolerated. Tubes: None Salem Sump Nasoduodenal PEG J-Tube pH: ______ Failure to Thrive: True. Deficient Knowledge False Waist belt restraint PRN; family sitter at bedside, assist with bath. Safety Increased acuity, Physiological Psychological Needs Normal acuity -Perform neuro assess She is also to receive radiation, chemotherapy, and hormone therapy post operatively. Offer assistance in providing more information about treatment options for newly diagnosed AIDS patients. Neuro WNL alert and cooperative. Notify doctor Impaired skin integrity: False, Anxiety: True Notify lead nurse/doctor Vital signs- Temp 98.7, BP 114/67, P 115, RR 20, SaO2 98%. Ask patient to explain to you what procedure she was expecting to have this morning. Tear, Ecchymosis, Contusions, Bruising Robert Sturgess 81 years old, Dx- Metastatic CA of Colon, Hx of diabetes. Surrounding skin: Moist/Intact Red/Erythema Irritation Fall, Risk for True Educate patient The patient got dizzy when he stood up from the commode. You enter patient's room. After two hours, Mr. Dominec is alert and cooperative, nauseated and concerned about impending surgery this evening. Noncompliance False -Explain to the patient that he has a procedure, and he cannot eat. You arrive in room to find Ms. Monson talking to herself. Scenario 2 Wash and glove hands Document results and findings -Provide a diversional activity to pass the time while waiting on the HCP and inform wife that the HCP will be coming soon Vital re-assessment Procedure is canceled for the day and rescheduled later allowing for new consent. No known allergies (NKA). Scenario 1 Vital signs are to be taken BID, and it is now time. Mr. Greer is on the floor still but is awake and oriented and is complaining of back pain below his right scapula. 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. Scenario 5 Mr. Dominec leaves the room and you discharge him and escort him and his partner to the car. Impaired comfort: True His wife tells the nurse that he seemed very distant and did not want to talk much. Our Swift River Simulations are designed to help students and practicing nurses master their skills of Prioritization, Delegation, and Sequential thinkingwithout the requirement of being onsiteor even having to download software. Pain: No Yes: Location: ______________________ Acute Chronic Constant Intermittent Vital signs -Temp 98.8, BP 102/76, P 102- irregular, RR 22, SaO2 90%, cardiovascular on telemetry with Sinus irregular rhythm. Don Personal Protective Equipment Full assessment The provider explains that it is a pre-cancerous stage in where the cell develops abnormal features. Ineffective self-health mgmt: False, Disturbed body: False 0800 1200 Toileting, Medications List/Times of Medications/Routes of medication, Neurological Assessment Pulse Ox: ___________ % on ____________FiO2; Room Air; Delivery Device 20ga. Inappropriate words = 3 Report this activity immediately to the hospital privacy officer Senario 4 Full head to toe neuro assessment. -Recheck Tilts after the NS bolus is complete.T Electrolyte Imbalance False His partner is at the bedside asking, "how much longer will he have to wait until taken to surgery?" Vital assessment Scenario 2 Cross), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. 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Encourage fluids and fiber diet Dr. Altace, Physiological- How does the Med-surg simulator work? Educate patient regarding patient care Apical pulse rhythm: Regular Irregular Location: Dx- urinary stones with 3 episodes/5yrs. Love and Belonging Reasses temp in 1 hour. Scenario 2 Description: Sharp Stabbing Throbbing Aching Cramping Other: You are about to call the Surgical ICU and give report. Notify doctor Psychological Needs Increased acuity NG tube to low suction possibly D/C'd today after Dr. Levine rounds.