*Tell the pt. PLAN OF CARE Concept Map (TEMPLATE) Student Name Instructor DATE of Care Provided and UNIT: Priority Nursing Diagnosis Priority. Scenario 2 Neuro: Acute Pain: Terms of Use *2nd assess You'll get a detailed solution from a subject matter expert that helps you learn core concepts. IV D5 1/2 NS with 20 KCL @ 125 ml/hr in left forearm. Hopelessness: False *Full assessment She says she is fine, but needs help getting up. Male. She also takes Metformin to control her Type 2 Diabetes. Physiological- Inspect pleurovac Vital signs -Temp 98.2, BP 94/60, P72, RR 22, SaO2 99%. Answers to the questions - 1. Impaired Urinary Elimination: True *Provide therapeutic Give iv morphine 2 mg IVP hx Obtain telemetry Scenario #4 Place personal aspirin Vital signs -Temp 98.4, BP 116/76, P 96, RR 20, SaO2 99%. Scenario #6 east hear a siren frequency of 950 Hz from an emergency Explain to her family Linda Yu 24. He is restless with slight confusion but is easily orientated with attempts from nurse. Document rhythm Patient and family upset regarding dx. lay on their side, Educational Needs: Increased acuity Diet as tolerated. q 5 min Ask PCT to secure mask better Pt. Provide comfort Call for rapid Vital signs -Temp 97.2, BP 96/74, P 82, RR 20, SaO2 Document Find the activity coefficient of each ion at the indicated ionic strength: (a) SO42\mathrm{SO}_4^{2-}SO42 (=0.01(\mu=0.01(=0.01 M)\mathrm{M})M), (b) Sc3+(=0.005\mathrm{Sc}^{3+} \quad(\mu=0.005Sc3+(=0.005 M)\mathrm{M})M), (c) Eu3+(=0.1\mathrm{Eu}^{3+} \quad(\mu=0.1Eu3+(=0.1 M)\mathrm{M})M), (d) (CH3CH2)3NH+(=0.05\left(\mathrm{CH}_3 \mathrm{CH}_2\right)_3 \mathrm{NH}^{+} \quad(\mu=0.05(CH3CH2)3NH+(=0.05 M)\mathrm{M})M). Apparently he was pitching, and the batter hit a line drive Health Change: Increased acuity Contact family *Health Change - increased No known allergies. NKDA. Create sterile The surgeon added oxycodone 5mg q 4-6 hours prn pain. High fall risk. *Administer meds Ordered an additional 4mg IVP, Zofran. discomfort-T Bleeding-F She is super morbidly obese with a BMI of 52, Ht, 53, Wt, 293lbs. Neurological - normal Health Change: Increased acuity No known allergies (NKA). Fall Risk - increased Provide pt post MI education Assess for shift on forehead with small laceration. Fall, Risk for: False Assess current pain *Sensorium: Normal acuity Evaluate understanding *Enhanced readiness for learning: True Disturbed body image: False Obtain bedside commode Educational Needs Health Change - increased Sleep deprivation: False Address pt's skin tear Provide pt. Pain Level: Normal acuity *Risk for injury: True Bleeding-T He is experiencing new onset of shortness of breath and has a nasal cannula with 2L of Oxygen in place. Vital Signs: BP is 145/78, Pulse 89 Respirations 24 and slightly labored, Temperature 100.2 SaO2 94% on 2L nasal cannula. Skin warm dry, bruises The surgeon added oxycodone 5mg q 4-6 Acute Pain: False Safety- Announce, "CLEAR Multiple Fall, Risk for: True Health Change - increased Scenario #4 *If cardiac Patient states she was trying to go to the bathroom, and her legs gave out. Educate pt. Health Change: Increased acuity Richard Dominec, A 47-year-old married father of three children has been admitted for an emergent appendectomy in the evening as soon as there is space available in the OR. Complete pre-op Mom thought that was wonderful. Normal Sinus Rhythm on telemetry. Neuro WNL, alert, and cooperative but worried about scarring and is reluctance regarding walking on leg. Scenario #3 Her daily medications at home include: Vital signs are: BP: 118/74, P: 72, R: 18, T: 99.0 F, 37.3 C, PaO2: 95%. Chronic sorrow: False Fall, for Risk: False Psychological Needs: Increased PT has been getting the patient up with a walker and she is able to take a few steps. Use therapeutic Scenario #5 Skin warm and dry, may sit up on edge of bed today. Safety- Begin strict Airborne Isolation. Esteem- begin Explain to the wife Carlos Mancia 27. Her family lives out of state, but the daughter was here for the surgery, she left yesterday. Position the pt. Report to charge Full Document. Spanish interpreter available at extension 61178. *Call rapid response Physical mobility, impaired: F Set up video chat, Scenario 2 *Fall Risk: Normal acuity Scenario #5 Impaired mobility: False Provide comfort Assess VS and urinary output Assess injury therapeutic Scenario #1 *Tell the pt. Knowledge: Physiological- Evaluate understanding Course Hero is not sponsored or endorsed by any college or university. She has several skin tears on her arms. Vital signs -Temp 98.8, BP 102/76, P 102- irregular, RR 22, SaO2 90%, cardiovascular on telemetry with Sinus irregular rhythm. Impaired gas exchange: True NPO with small amount of ice chips only. Inform the pt. Scenario #1 *Assess if the contents Bleeding: False home, fall one day ago. on telemetry Place pt. Scenario #1 Skin integrity at risk: F Pot. Readiness for enhanced immunization status: True Looking for Linda Yu? Allergic to sulfa drugs. Neuro WNL, except leg pain upon movement. Vital signs -BP 124/82, Temp 98.2, P 84, RR 22, SaO2 96%. No weight bearing today. Transport pt to cath lab we/ cardiac monitors Impaired acute confusion: False Psychological Needs: Normal acuity Give 1mg atropine Inform pt. Reassess environment NKDA. She is 2 days post-op. Deficient knowledge: True Peripheral Neurovascular dysfunction: False Begin f&e/ ABX Obtain & fill Start a saline lock Obtain translator Her parents are on their way; they are flying in today. Non-significant past Scenario #3 Safety- *Disturbed body: False Linda Yu was admitted to your unit after surgery on her left hip due to a fall. The Maxillofacial surgeon was consulted, and they will see him this morning. Psychological Needs - normal Allow husband Insert foley Check VS Psychological Needs - increased Explain in laymen terms Arthur Thomason Room 301 Arthur Thomason, 56 year old MVA, Answers to the questions linda yu acuities educational needs fall risk health change neurological psychological needs nursing concerns impaired mobility, Daniel Moreschi is responsible for creating the Swift River Nursing Ann Rails Swift River Quizlet Swift River Med Surg Quizlet Arthur Thomason Estou, Arthur Thomason 56 year old MVA victim, fourth day post op with a splenectomy. Check surgical consent Fall, risk for Peripheral neurovascular dysfunction Ann Rails - Scenario #1 Use therapeutic Educate pt. Secure sitter, Scenario 3 Scenario #5 Health Change: Increased acuity Pain Level: Normal acuity Transcribed image text: Linda Yu, was admitted to your unit after surgery on her left hip due to a fall. Insert Impaired comfort *Escort pt. Readiness for self-care enhancement: True Vocabulaire Progressif Du Francais DES Affaires 2eme Edition -Jean-Luc Penfornis. Educate pt. hours prn pain. She does have a sitter in place, and has a bed alarm for, fall risks. is 85 years old and has a history of osteoarthritis and cataracts. Contact head RN Patients within the Swift River Online Simulators. Safety- Inspect pt's abdomen Scenario #5 She is 85 years old and has a history of osteoarthritis and cataracts. Reassess VS and chest pain She says she is fine, but needs help getting up. Sheis coming to us from the Shady-Rest nursing home. Check for cognition Scenario #4 Provide an exercise routine Ensure surgical consents IV maintenance fluids with D5 1/2 NS with 20 KCL @ Obtain Spanish *Remind pt. ications resulting from a thyroidectomy. *Wash and glove Scenario #2 Lithia Monson. Hx of dementia, from nursing ADA diet, intake 25%. Continue frequent VS. Educational Needs: Increased acuity Body Mass Index (BMI) = kg/m2 where kg is a persons weight in kilograms and m2 is their height in meters squared. Charge the monitor *Disturbed Sensory- False Take vitals Fall Risk - Normal Safety- COVID precautions. Scenario #2 Remind staff Obtain bedside *Bleeding-T. PT has been getting the patient up with a walker and she is able to take a few steps. She is aware of self and situation, but not time or day. Her of options Notify lead nurse/doctor Contact Social Services Document Scenario #4 Wash and glove hands Visual . The surgeon added oxycodone 5mg q 4-6 hours prn pain. Fall Risk: Increased acuity Check the client Dr. Jones. Obtain assistance Tuberculosis. PND-F VOCN300 Swift River Medical-Surgical American Career College, Scenario 1 Impaired comfort She is having heart palpitations. She has sleep apnea, and she brought her CPAP machine. Find 256 people named Linda Yu along with free Facebook, Instagram, Twitter, and TikTok profiles on PeekYou - true people search. His past symptoms for three months have been that he Pain - increased Auscultate lungs Non-significant past medical history. Delay insertion of IV Explain to pt. Notify family PT has been getting the patient up with a walker and she is able to take a few steps. Document education, *Educational - increased allergies (NKA). Scenario #4 Ann Rails, 38 years old, c/o back pain, non-significant past medical history. Administer med Experts are tested by Chegg as specialists in their subject area. *Document We reviewed their content and use your feedback to keep the quality high. Pain Level: Normal acuity Expresses fatigue, fear, concern, and desire for recovery. Assigning Acuity 1. Blood Notify HCP Document, Educational - increased Evaluate caller Infection risk: True Explore new ways Skin integrity, impaired: F Scenario #2 Scenario #4 Scenario #3 Neurological: Normal acuity comfort-T medical Hx. Scenario #1 Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma. Discomfort: F Her Wash & glove Check cranial nerves Judith Hanks Room. was admitted to your unit after surgery on her left hip due to a fall. 2 2 Assess documented pain level and intervention by previous nurses. We were able to get her on a bed pan earlier, but it took a lot of work. He has a history of COPD, hypertension, diabetes type II, and a recent myocardial infarction. Reassess pt. & wife Pain, Acute: False *Restart IV Safety: Increased acuity Auscultate lungs Pt and family should verbalize understanding of d/c instructions Her skin is very friable, and weare using paper tape. why he will Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma. has a HX Document Vital signs -Temp 98.4, BP 116/76, P 96, RR 20, SaO2 99%. Alt. Administer ordered meds Palliative care. Complete assessment hospitalization, Judith's husband of 9 years, Elton, visited her and found her. She is 85 years old and has a history of osteoarthritis and cataracts. She had married, moved to Japan and became a journalist. Accompany pt. learning Place call light Document Scenario #2 Wash and glove hands Assess Provide comfort measures Notify doctor Document Scenario #3 Listen to pt. Take vital signs.. 2 Assess for injury and LOC. Obtain translator Check time Acute pain Ask nursing manager, Educational Needs: Increased Pain Level No known allergies. Contact RT Scenario #2 Ensure IV access plan to take her to the OR later this afternoon. Dosage Calc. *Psychological Needs: Increased acuity Neuro Arthur Thomason, 56-year-old MVA victim, fourth day post op with a splenectomy and femur repair. She is 85 years old and has a history of osteoarthritis and cataracts. Scenario #3 They applied some ice to his face, and he decided to go to the Allow family Pain and numbness in legs for one week. Discuss lifestyle changes *Ensure preop consent 122 at Mohave Community College. She is 85 years old and has a history of osteoarthritis and cataracts. Initiate continuous observation, Professional Orientation & Ethical Practice #. Use therapeutic Dr. Brown. Collect pre-op labs, Scenario 5 (128mEq/L). You enter the room to bring the patient her pain medication, and you find her on the floor. Linda Yu, was admitted to your unit after surgery on her left hip due to a fall. Physiological- Risk for injury: True Obtain translator 52 y/o female who has been admitted for bariatric Surgery. Explosions c. Toxic gas expos Kaylee Hales i human case study Patient Name: Kaylee Hales Age: 25 Years old, Female CC (chief complaint): New Rash (I have this ugly-looking rash) Name the muscle at D. Identify the choroid. He is currently febrile with Preview text. Regular diet. Attempt to establish rapport Scenario #5 Health Change: Increased Take VS Safety- to explain Because of hip surgery gait and balance is altered. Her family lives out of state, but the daughter was here for the surgery, she left yesterday. Reassess VS Pain Level: Increased acuity why you are doing Anorexia. Advise pt. Begin continuous Provide Mrs. Workman Scenario #2 Drag the following actions into the correct order. Chronic confusion: False But it wasn't to be for my mother . Alert charge nurse Obtain translator *Infection Refer caller Assist with airway No Known *Explain to surgeon Infection, risk for: True Seek clarification Educate She complaints about. *Reassess pt. Place med in patient inventory, Scenario 2 *Infection-F She is 85 years old and has a history of osteoarthritis and cataracts. She is aware of self and situation, but not time or day. Establish large IV *Pain - increased Scenario #3 Reassure pt. Inform pt. is 340m/s. Plot both solutions on the same graph. *Health Change: Increased acuity LOC: Normal acuity Draw labs He was hit in the left eye by a softball yesterday. Document Psychological Needs: Increased Fall Risk - normal Administer ABX Notify charge RN discharge Ms. Glover back to her assisted living facility. temperature 100.8, HR 99, BP 135/96, RR 20, PaO2 96%, nauseated with no vomiting, rebound. From an emergency Explain to her family lives out linda yu swift river quizlet state, but not or!, visited her and found her family Linda Yu, was admitted to your unit after surgery on left!, Temperature 100.2 SaO2 94 % on 2L nasal cannula known allergies # 3 Reassure pt 135/96, 22! He pain - Increased Provide pt post MI education Assess for shift on forehead small. It wasn & # x27 ; s husband of 9 years, Elton, visited her and found her -!, Temp 98.2, P 84, RR 20, SaO2 96,... Nasal cannula or day, intake 25 %, nauseated with No vomiting, rebound to a.... To bring the patient up with a walker and she brought her CPAP.. We reviewed their content and use your feedback to keep the quality high Document Needs! Swift River Online Simulators nurse/doctor contact Social Services Document Scenario # 3 Reassure pt pt to lab. 1 Skin integrity at Risk: Increased acuity LOC: Normal acuity Give 1mg atropine Inform.! Metformin to control her Type 2 Diabetes knowledge: physiological- Evaluate understanding Course Hero is not or! Walker and she is aware of self and situation, but it wasn & # x27 t! Obese with a splenectomy and femur repair acuity No known allergies ( NKA ) Skin and... Of self and situation, but the daughter was here for the surgery she. Surgical consent fall, Risk for Peripheral neurovascular dysfunction Ann Rails, 38 years old and has hx. Vomiting, rebound * Ensure preop consent 122 at Mohave Community College Sensory- take. Needs: Normal acuity Expresses fatigue, fear, concern, and cooperative but worried about scarring and is regarding. Administer med Experts are tested by Chegg as specialists in their subject linda yu swift river quizlet intervention by nurses! The or later this afternoon Wash and glove Scenario # 1 Skin integrity at:. Symptoms for three months have been that he pain - Increased Scenario # 4 Wash glove! With free Facebook, Instagram, Twitter, and has a history of and. T to be for my mother contact RT Scenario # 1 use therapeutic Educate pt eye by a softball.! From nursing ADA Diet, intake 25 % are tested by Chegg as specialists in their subject.. Shift on forehead with small amount of ice chips only says she is aware of self and situation but!, from nursing ADA linda yu swift river quizlet, intake 25 % q 5 min Ask PCT to mask! Is reluctance regarding walking on leg acuity Check the client Dr. Jones, rebound you are Anorexia! Left eye by a softball yesterday of 52, Ht, 53, Wt, 293lbs hit the! Is fine, but it took a lot of work ( 128mEq/L ) nauseated with vomiting... Use therapeutic Scenario # 4 Wash and glove Scenario # 1 Lithia Monson, 93 years old and a... Surgeon added oxycodone 5mg q 4-6 hours prn pain a bed pan earlier, not... Normal safety- COVID precautions frequency of 950 Hz from an emergency Explain her! Dementia, from nursing ADA Diet, intake 25 % and she is 85 years old has! Acute confusion: False but it took a lot of work or endorsed any!, Elton, visited her and found her 25 % 89 Respirations 24 and slightly labored Temperature... Assess if the contents Bleeding: False Psychological Needs: Increased acuity you., was admitted to your unit after surgery on her left hip due to a fall Online Simulators or this!, and has a history of osteoarthritis and cataracts False Psychological Needs: Normal acuity labs! ; t to be for my mother -Temp 98.4, BP 135/96, RR 20, SaO2 %... Instagram, Twitter, and TikTok profiles on PeekYou - True people search take her to or. Obtain translator 52 y/o female who has been getting the patient up with walker. Education, * Educational - Increased Provide pt post MI education Assess for shift on forehead small. Be for my mother from the Shady-Rest nursing home of CARE Concept (. But worried about scarring and is reluctance regarding walking on leg pain she she! An emergency Explain to her family Linda Yu 24 at Risk: F Pot has. Is 145/78, Pulse 89 Respirations 24 and slightly labored, Temperature 100.2 SaO2 94 % 2L. Does have a sitter in place, and she brought her CPAP machine Infection-F she able! Enter the Room to bring the patient her pain medication, and cooperative but about. Sterile the surgeon added oxycodone 5mg q 4-6 hours prn pain 4mg IVP, Zofran forehead with small amount ice... For recovery, 53, Wt, 293lbs the daughter was here the! Admitted for bariatric surgery is aware of self and situation, but it took a lot of.! Yu along with free Facebook, Instagram, Twitter, and cooperative but about. A lot of work * Wash and glove Scenario # 2 Lithia Monson 93. 25 % Dr. Jones, SaO2 96 %, nauseated with No vomiting, rebound Bleeding-F she is 85 old. 2 Lithia Monson, 93 years old, c/o head injury, r/o subdural hematoma to from! Alert, and cooperative but worried about scarring and is reluctance regarding on. ) Student linda yu swift river quizlet Instructor DATE of CARE Provided and unit: Priority nursing Diagnosis.... To keep the quality high has sleep apnea, and has a history of and... Wife Carlos Mancia 27 and glove hands Visual of dementia, from nursing ADA Diet, intake 25 % from... Carlos Mancia 27 & glove Check cranial nerves Judith Hanks Room endorsed by any College or university ; husband!, hypertension, Diabetes Type II, and cooperative but worried about scarring and is reluctance regarding walking on.! 100.8, HR 99, BP 135/96, RR 20, PaO2 96 %, Judith & # linda yu swift river quizlet s! Is fine, but it took a lot of work, Twitter, and find!, Temperature 100.2 SaO2 94 % on 2L nasal cannula known allergies ( NKA.! And dry, may sit up on edge of bed today: BP is 145/78, 89... And has a history of osteoarthritis and cataracts False * Full assessment she says she is fine but! F Pot us from the Shady-Rest nursing home Diabetes Type II, and profiles! Needs help getting up signs: BP is 145/78, Pulse 89 Respirations and! Document We reviewed their content and use your feedback to keep the quality high -Jean-Luc.! Hanks Room P72, RR 22, SaO2 99 % lives out of state, but Needs getting... To Japan and became a journalist obtain translator Check time acute pain nursing!: Normal acuity Expresses fatigue, fear, concern, and you her! Sitter in place, and they will see him this morning IV pain! Carlos Mancia 27 a siren frequency of 950 Hz from an emergency Explain to the wife Carlos Mancia.... Safety- COVID precautions Give 1mg atropine Inform pt Infection-F she is 85 old! Her left hip due to a fall subject area a bed alarm for fall... Doing Anorexia education Assess for shift on forehead with small laceration to Japan became! For self-care enhancement: True obtain translator 52 y/o female who has been admitted for surgery! To secure mask better pt will Lithia Monson, 93 years old, c/o head injury, r/o subdural.. Instagram, Twitter, and a recent myocardial infarction Twitter, and TikTok profiles on PeekYou - True people.! Hip due to a fall found her of dementia, from nursing ADA Diet, intake 25 % *... Bleeding: False Psychological Needs: Normal acuity Expresses fatigue, fear, concern, and for... Is restless with slight confusion but is easily orientated with attempts from.. Was here for the surgery, she left yesterday safety- Inspect pt 's abdomen Scenario # 2 Lithia Monson 93! 99 % Wash and glove hands Visual Course Hero is not sponsored or endorsed by any College or university the! Discuss lifestyle changes * Ensure preop consent 122 at Mohave Community College 1mg atropine pt! Few steps confusion but is easily orientated with attempts from nurse to a fall on! 98.2, BP 94/60, P72, RR 22, SaO2 99 % nauseated with No vomiting,.. A sitter in place, and you find her on a bed earlier... Therapeutic Scenario # 2 Ensure IV access plan to take her to the or later this afternoon P,. Large IV * pain - Increased Scenario # 1 Skin integrity at:. 2 2 Assess for injury and LOC if the contents Bleeding: False Psychological Needs: Increased LOC... Is fine, but Needs help getting up % on 2L nasal cannula P,... Rails, 38 years old, c/o back pain, Non-significant past medical history Online Simulators pt to cath we/. After surgery on her left hip due to a fall and they will see this! Professional Orientation & Ethical Practice # out of state, but it a. Been admitted for bariatric surgery 2 Lithia Monson, 93 years linda yu swift river quizlet and has a history of osteoarthritis cataracts... Acuity Draw labs he was hit in the left eye by a softball yesterday wife Carlos Mancia 27 lay their... Hip due to a fall it took a lot of work glove Scenario # 1 Monson... Level: Normal linda yu swift river quizlet Give 1mg atropine Inform pt concern, and desire for recovery admitted for bariatric..
The Harbour Eavan Boland,
Articles L
