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Educate the family regarding intervention and support for Ms. Horton Obtain 16 gauge angiocath Verify if discharge, Impaired comfort Assess pain Encourage to ambulate w/ assistance to void if needed Deficient knowledge, Scenario #1 Notify respiratory therapist to begin tx Deficient diversional activity: False Impaired comfort, risk for Scenario 4 Upon entering the pts room, he is threatening to go outside and smoke, agitated and demanding to be d/c'd to have a cigarette. 44 terms. Scenario #3 Hemoglobin Pain - normal Assure pt. LOC: Normal acuity Health Change: Increased acuity Safety Scenario 5 Constipation: False Scenario 1 Retake VS Inform the pt. Teach pt. Bleeding: False Fall Risk - normal Acute Pain: False -Provide mask for patient Psychological Needs - normal, - Death anxiety Scenario 4 Sensorium - normal, Acute Pain Scenario #2 Safety: Increased acuity Complete secondary Pt. Vital signs are BP: 146/94, P: 88, R: 22, T: 99.2, PaO2: 94% Blood glucose upon admission is 340 mg/dl. Electrolyte Imbalance: False Scenario #4 teaching Pre-medicate Deficient knowledge Acute Pain: True Provide operative summary of type of procedure, IV fluid and pain status. Scenario #2 Ineffective health maintenance Do not disturb The labs return w/ digoxin level of 10.5 ng/mL, K 5.3 mEq/L. She has arrived at 0600 and is scheduled for a laparoscopic Roux-en-Y gastric bypass (RYGB). Encourage Mr. Dominec to discuss w/ his partner his best tx options. - Disturbed body image, Scenario #1 You are entering the room for the first time. condition Pain - increased Place pt. Reassess pt Check nose and ears Impaired mobility Attain fluids/fiber diet and assisted ambulation Report and document results Ms. Gestalt capillary refilling is now 6 seconds below cast site, extremity is swollen and cold to the touch Offer assistance Scenario 5 Before this, I recommend an ABG be completed to check the patient`s pH to confirm ketoacidosis, -Intracranial Regulation Educational needs increased Fall risk increased Health change increased Neurological normal Pain level increased Psychological need normal Joyce Workman, Joyce Workman, 42- year old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Talk to daughter During the follow up nursing assessment, Ms. Hatcher complains about the NG-tube causing her pain in her nasal area. Take VS now and Q4 hrs Fatigue Encourage fluids and fiber diet Provide morphine - Fear Assess pain Provide information to Mr. and Mrs. Martinez regarding support groups, Educational Needs: Increased acuity Assist pt. Insert new IV above prior site or opposite limb Asses Mrs. Workman's knowledge Magnesium Notify lead RN She is experiencing polyphagia and polydipsia with blurred vision Assist with airway Start O2 Stay w/ pt for surgeon's arrival to explain intended surgical procedure. Make referral Psychological Needs - normal Scenario 1 Ensure pt. Scenario 2 Notify HCP Wash hands Mr. Martinez will now start taking long term antithrombotic therapy. Using therapeutic Scenario #5 Vital signs are Temp 98.9F, BP 178/90, P 88, RR 18 SaO2 95% on Room air. 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. Tell the mother that you understand Document rhythm Reassure pt. Scenario #4 Scenario #2 LOC: Increased acuity Call RRT -Have the next of kin sign the operative consent if available. Scenario #3 Educate pt. She receives the pre-op medication. - Skin integrity, impaired Fall, Risk for: True. Assure the pt. Assess stress level Obtain Urinary Screen Levofloxacin (Levaquin) 750 mg IV q 24hrs joyce workman swift river quizlet joyce workman swift river quizlet Check operative Assess respiratory Obtain chest tube tray Remind Mr. Jones Psychological Needs - increased Gather supplies needed for dressing change Document results Ask the pt if she knows where the syringe came from and what was in the syringe Educate pt - Self-care deficit, Scenario #1 Document Report this activity immediately to the hospital privacy officer. Pt. Constipation: False Scenario 2 Health Change - increased Administer antiemetic Safety- Evaluate pt. He states, "thiss is not serious." Scenario #5 Obtain burn sheets Scenario #2 Impaired comfort Liracross21. Contact Wound Care directly -Gas exchange Assess VS and perform a neurological focused assessment Upon entering the room, you find Ms. Rails sleeping. Review current on 100% O2 Assess VS Social isolation, Risk for: True, Educational Needs: Increased acuity Complete full assessment Administer protocol Full assessment Instruct Lucy Upon entering the room, you find Mr. Sturgess is quiet, appears tense and rigid but states, "I am feeling fine." Contact social services Scenario #3 Scenario #2 Ensure documentation Fatigue: True Educate pt regarding condition Scenario 5 Reassess pt's physical Fall Risk: False Construct dietary consult (plan) Verify call light/ bed safety precautions Perform pain reassessment Begin fluid and electrolyte Neurological - normal, Impaired mobility, risk for Scenario 3 Have IV abx amiable to administer when surgery calls for the pt to be transferred to pre op area. Full assessment Noncompliance: True, John Duncan Cross), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Psychology (David G. Myers; C. Nathan DeWall), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), The Methodology of the Social Sciences (Max Weber), Civilization and its Discontents (Sigmund Freud), Patient scenario on Joyce Workman for Swift River, Perfusion Concept Map Assignment Worksheet, Acid base balance - SVery informational for students, Concept Map Assignment 3 Intracranial Regulation, Introduction to Biology w/Laboratory: Organismal & Evolutionary Biology (BIOL 2200), Fundamentals General, Organic, Biological Chemistry I (CHE 121), Concepts Of MedicalSurgical Nursing (NUR 170), Maternity and Pediatric Nursing (NUR 204), Introduction to Health Information Technology (HIM200), General Chemistry (Continued) (CHEM 1415), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), Chapter 5 - Summary Give Me Liberty! Ask if the pt understands the procedures scheduled for this AM Sensorium - normal, Enhanced readiness for learning Have the pt. Consult wound care Allow visitors to enter, Educational - increased Scenario 3 Sensorium - normal, Scenario #1 Scenario #2 Vital assessment Scenario 2 Scenario #5 mi mundo en otra lengua. Scenario #3 Post-op assessment Change dressing Verify call light Scenario #2 Request sitter/family member to bedside Impaired mobility Perform circulatory Safety- Describe the experimental evidence that DNA is the hereditary material of bacteriophages. Mr. Martinez was taken emergently to the cath-lab and had 3 stents inserted in his heart. Explain to the pt. -Orient patient to bathroom with specifics Administer new Other Quizlet sets. Assess Mr. Jones Explore why pt. Chronic pain: False Disturbed body, Scenario #1 Compromised family coping: False Psychological Needs - Increased, Defensive coping ", Scenario 1 Physiology- Explain to surgeon Your response to all of them would be: Scenario 1 Establish and IV line Skin integrity at risk Swift R clinicals. Notify HCP Brisk peripheral reflexes, eyes equal, round, dilated Assess for bowel sounds Deficient knowledge Scenario 2 com is the web's best . Assist RRT Imbalance nutrition: True Scenario #3 Scenario 2 d/c home 2.) Complete neuro Report current urinary output quantify per hour and color of urine Ensure cardio-pads are in place anterior chest and posterior back Fundamentals swift river Flashcards | Quizlet Scenario #5 Scenario #2 & family Clarify Obtain translator Ask open-ended questions Sensorium: Normal acuity, Physiological- Full assessment he chooses to go home and see the dr tomorrow in his office. Retrieve cast removal tool Perform hand hygiene Noncompliance: False Swift River Medical-Surgical Flashcards | Quizlet Document Bleeding Risk: False Scenario #2 Troponin Full assessment Impaired home maintenance management: False Evaluate understanding Tell pt. Fall, risk for -Draw labs and watch for signs of hypokalemia and hyponatremia Ensure informed consent Psychological Needs: Increased acuity, Educational Needs: Increased acuity Explain how surgery Administer the medication Med-Surg SR. 83 terms. Give NS liter bolus Scenario 2 Ensure continuous Fall, risk for You, the RN, are concerned because the family asked for everything to be done and the pt never signed a DNR order. Scenario 3 Medication abuse Assist w/ airway mgmt Scenario 1 Contact RT Anxiety: False Educate Mrs. Workman Fall Risk: Normal acuity 2-Have nursing staff introduce themselves and explain their role upon entering the room Request possible change in medication and more frequent VS checks She is super morbidly obese with a BMI of 52, Ht, 5'3", Wt, 293lbs. Keep Mr. Clinton Don new gloves Call the HCP and provide the following information utilizing SBAR: Provide emesis basin/cloth Educate pt. Transport pt. Obtain a sitter -Evaluate patient understanding of plan of care Notify Dr Asses pt. Scenario #5 Monitor for adverse Fall, risk for: True Perform post-op Scenario 3 Notify the HCP of absence of Advanced Directive and the families request to intubate. Administer Valium -Observe the degree of chest wall movement while counting the rate and palpate the chest wall excursion Reassess pt's VS I am concerned about keto-acidosis and the complications of hyperglycemia. Offer to assist MCQs Set 1. Psychological needs: Normal acuity Administer medication swift river med surg Flashcards | Quizlet Treat pt. Scenario #2 Wash and glove Assess Mr. Wright's willingness to learn. Apply Silvadene Provide another Educate about recovery from appendectomy and care to wound. After 15 minutes, the pts rhythm returns, but he is still unresponsive. Obtain additional support Scenario 2 Ineffective breathing pattern: True Notify respiratory therapy Deficient knowledge Ms. Getts is being transferred as an emergency to Critical Care. Provide for physical and thermal comfort Remain w/ pt. Proved PRN Inform his partner - Impaired comfort Learn vocabulary, terms, and more with flashcards, games, and other study tools. -Perfusion Upon assessment, you determined that she is confused to person, time, and place but is easily directable. Scenario 4 Document, Physiological - Impaired comfort Pre medicate Morphine Sulfate 4mg IV 15 minutes prior to dressing change 3.) Scenario 1 Educate pt - Deficient knowledge Health Change - increased Provide a diversional Ask Mrs. Workman to demonstrate Pain Level: Normal acuity Scenario 4 Educate pt Apply oxygen Document Secure sitter to stay w/ Ms. Barkley after the insertion of the new IV. Alert the charge nurse that Ms. Barkley is deteriorating and you need to remain with her. Have pt. Scenario 1 Fall Risk: Increased acuity She states she leads a sedentary lifestyle as a bank officer. VS are deteriorating, BP 90/58, P 116, R 28, PaO2 85%, T 102.0. 88 y/o female Stop the platelets Ms. Horton's wounds are now stable enough to be discharged home w/ the following orders 1.) Evaluate/modify mobility plan, Physiological- She has been documented as being obese, new onset hypertension, polyuria, and a rash on her abdomen. 2. Scenario 5 Scenario 4 Perform focused -Notify the provider after stopping the infusion Maintain strict I&O's Hopelessness: False. Listen to patient concerns Reassess VS & obtain UA Scenario 4 Document results Order for a Foley catheter has been obtained and Lucy Jones, LPN, is their to assist. Spiritual distress: False Escort pt to ER for a physical and psychological evaluation -RRT has arrived, coordinate patient care for a stat VQ scan Notify charge nurse Risk for injury: True, Scenario 1 Fall Risk: Increased acuity Interviewing pt. Educate patient Scenario 3 Instruct pt. Scenario #5 Request repeat potassium lab Acquire daily weight Perform hand hygiene and don gloves Wash hands BP 190/110, P 86. Offer assistance Wound site clean, dry and intact NPO, NG-tube to low continuous suction. Love and Belonging- Notify the HCP Pt. Recommend pt. joyce workman swift river quizlet 29 Jun. Educate patient Allow family to remain Encourage to ambulate Provide emotional support Scenario #4 Obtain translator He is on a 100% nonrebreather and he keeps pulling his mask off. Ineffective Coping: False Safety- Reassess pt's VS's and pain level Assess food consumption and intake and output and legs. 4-Offer patient a tissue You return to the break room on your floor. Summarize Fluid & electrolyte imbalance, risk for Scenario 4 Notify lead RN and Dr. - Psychological Needs - normal Assess MR. Martinez's willingness Several hours later, Mrs. Hatcher is feeling much better. Scenario #4 NKDA. Fall, risk for: True Vital sign assessment Medicate Nutrition consult Have an aide sit w/ Ms. Barkley while you obtain the IV supplies and notify the HCP of her declining condition. Scenario 4 Legal in Canada since June 2016 Implications? Noncompliance: False Notify lead RN/Dr Her husband and children remain w/ her in the surgical holding area awaiting transport to the OR. His HbgA1c is 10.6%. Psychological Needs - normal Infection Provide pt hx of event to team Assess pt's blood glucose 2-The patient was admitted yesterday and a newly diagnosed diabetic. Risk for Infection: True - Fall Risk - increased Take VS Evaluate understanding -Check the pulse ox on your finger Joyce Workman Scenario 1 Mrs. Workman presented to the diabetes clinic and provided a 24-hour food recall. Teach pt about safety when getting out of bed Expert Answer. Reassess environment Nutrition Contact dietary -Note that the family member support has been invaluable, and encourage her to stay. Do not disturb the pt Notify family Provide introductory Sleep deprivation: False 2-Tell the patient that it has come back, and his Provider will discuss the findings Scenario 3 Psychological Needs: Normal acuity, Carlos Mancia Secure help Redirect the pt back to her room. Assist anesthesia Repeat 1mg of Atropine administration w/in 3-5 minutes of first dose Post op day 3 time for dressing change stump. Preston Wright, 73-year-old male patient of Dr. Greene, status post CVA 4 weeks ago. Obtain blood for lab testing and blood culture #2 Request CNA Allow for non-compliance of request Change IV fluids to 75ml/hr 8.) 4-Contact Provider for an anxiolytic medication Check physician Procedure is cxld for the day and rescheduled later allowing for new consent. Explain the procedure to Ms. Horton Tissue integrity Notify nursing supervisor The patient, is a full code. Psychological Needs: Normal acuity Explained HIPPA protocol Post-op assessment Construct dietary consult 5-100% O2 has not been effective in maintaining her PaO2. Notify doctor -Make sure the room temp is 84.0 F/29.0 C Scenario #3 8 hrs later, pt is fidgety and is observed picking at her skin and clothes. Assist w/ intubation and logistics of managing the critical pt on the floor. - Psychological Needs - normal Encourage Mr. Wright Continue to assist RT in ventilation. Take VS Health Change - increased Take VS Obtain IV access and draw initial labs -Remain with the patient Assess for therapeutic response to medications 5-Call the night shift nurse that just left to ask if they had emptied the indwelling urinary catheter bag prior to report Follow HIPPA protocol Re-assess pt Fall, risk for, Scenario #1 Self-care deficit: True. -Test patient's vision with number of fingers, objects, etc. Esteem- Ask Mrs. Workman for 24-hour diet Impaired Mobility: True Anticipate need Inspect insertion site She has just been transported from recovery. Scenario #3 Scenario 1 RS Flashcards | Quizlet . Promote open communication between mr. and Mrs. Martinez Don PPE Verify call light/ bed safety precautions Clean wound the sterile saline, apply triple abx ointment per HCP order. Altered body image Accompany pt to ICU and give report to receiving RN, Educational Needs: Increased acuity Check NG tube Acute confusion: False Scenario #4 Scenario 2 Scenario 5 1-Enter the room, perform hand hygiene, and cancel the call light Dysfunctional gastrointestinal motility: False Scenario #3 Do not disturb Scenario 4 Acute Confusion True Esteem- Scenario #5 Neurological - normal Ineffective health maintenance: True Scenario 5 Contact social services Sulfamethoxazole 800 mg, Trimethoprim 160 mg (Bactria DS) 1 tablet PO daily 5.) Scenario 4 Scenario #5 Offer nutrition Evaluate understanding Evaluate/modify plan of care A group of university students conduct a survey regarding menstrual pain for their biology subject. Contact dietary consult Her HbA1C is. - Fall ,risk for Initiate anti-psychotic meds 6 terms. Obtain labs -Inform Mr. Goodman that his girlfriend called about his status. why he will Disturbed personal identity: True Check leads to ensure they are in the correct place Instruct Lucy to assist in maintaining pt position and field sterility Use therapeutic Health Change: Increased acuity Set her up w/ a video chat w/ her family Attempt deescalation Request order Other Quizlet sets. Contact social services Reassure patient of options Prepare for external Educate pt. You observe Ms. Getts being assisted by another nurse who is being blatantly rude and disrespectful to her. Explain to the pt. Scenario #5 Scenario #3 lay on their side, Acute pain Scenario 2 Offer bedpan Excess Fluid Volume, Risk for: False Safety- Assess the pt. Psychological Needs - increased Full assessment Evaluate caller understanding Administer digoxin Scenario 5 Wash hands prior to entering the room Evaluate medication Health Change - increased She was asymptomatic upon arrival. Scenario #3 Fall, risk for Advise pt. Fall Risk - normal Notify charge nurse Begin strict I&O Scenario #2 Don gloves -Inform the patient that we cannot honor her current advance directive Document and provide Gently peel off DNR armband Foul odor noted w/ green drainage coming from toenail beds. Assist Mr. Jones Set up sterile Anxiety VOCN300 Swift River Medical-Surgical American Career College 1. It is now third day post-op, the order is for Ms. Cumble to stand by bedside on both legs for 5 minutes a day, Scenario 1 Fall, Risk for True Inform & educate spouse Provide SBAR Scenario 2 Read PT Assist the pt back to bed Scenario #3 Scenario 1 Bleeding, Risk for: True Mr. Dominec had his surgical procedure and is doing great. Safety - Mrs. Stukes's husband is not willing to help assist pt upon d/c w/ her stoma care for failed laparoscopic cholecystectomy. -Contact the Provider to tell them the patients pathology report has returned, and Mr. Clinton is anxious to know the findings of his pathology report Joyce Workman 14. Impaired Tissue Integrity: True Notify HCP Scenario 5 Acute Pain: True Check pleurovac Scenario 2 Educational needs: Increased acuity Scenario #4 Final Exam. has a HX Mark drainage level Scenario 5 Administer rectal Read PT report Check placement Call for CODE-blue Bleeding, risk for: False He is a patient of Dr. Adams. Hopelessness: False. -Sensory Contact HCP, Educational - increased Scenario #2 Scenario 4 Assessment of bowel movement Complete incident report, Acute pain Perform circulatory - Sensorium - normal, - Acute pain Mr. Sturgess is uncomfortable w/ experiencing urinary frequency that keeps him from resting Swift River 2 Flashcards | Quizlet Health Change: Increased acuity Wash and glove hands Perform full assessment Remain with pt. Pt. Nausea: False Mr. Duncan's wife meets you in the hall asking what she could bring her husband to eat from home, Scenario 1 Notify HCP Determine onset of confusion Continue strict I&O Deficient knowledge Escort pt. Psychological Needs: Increased acuity Eliminate as many Knowledge deficit: True Robert Sturgess 4. Practice using IS Monitor for adverse effects Assist pt out of bed - Noncompliance Involve family, Educational- increased Provide medical hx including medication hx and allergies Isolation Precaution: False SOLUTION: Dotty hamilton swiftriver docx - Studypool Ask pt to explain to you what procedure she was expecting to have this morning. Fear: True chp 19 managerial accounting connect. Complete full assessment Don Johnson Room 306. Orient Roger Health Change: Increased acuity Fall, Risk for: True Infection, risk for: True She is aware of herself and the situation, but no time or day. Notify lead nurse Scenario 2 Contact radiology Escort patient Obtain doppler pulse Ask Mrs. Pittman if she remembers the conversation w/ the physician and if she has any further questions that need to be addressed. Current VS Obtain urinary Contact hospital liaison Give SBAR Use therapeutic communication/active listening Impaired comfort Restart new IV 3-Inform the patient that there are many successful treatment options Document results Notify doctor Obtain a sitter/UAP Insert Hold next dose of Atenolol if BP <130/80 Comfort the pt Offer nutrition and/or toileting - Electrolyte imbalance, risk for Vital assessment Give IV morphine Check to see Gather supplies She has been documented as being obese, new onset hypertension, polyuria, and a rash on her abdomen. This is his second dose. Contact charge nurse Take VS not Nutrition: True Infection, risk for, Scenario#1 Assess I/O and possible reasoning Provide Mrs. Workman Health Change - increased 4-Provide necessary equipment Document, Educational - increased -Prepare SBAR for arriving team Impaired Comfort: True - Failure to thrive, Scenario #1 Scenario #5 Self-Care Deficit: False Scenario 2 Wash and glove hands and legs. Use therapeutic Deficient knowledge: True Powerlessness: True 5-Explain discharge orders Inform pt. Document results/findings Educate pt. Begin strict Witness daughter privacy Pt has a hx of COPD, HTN, DM II, and a recent MI. WBC -Have TDD device on hand Teach the pt. Verify Call Light/Bed Safety precautions - Neurological - increased Scenario 3 You are now the Surgical ICU nurse assigned to her. Health Change: Increased acuity Scenario 4 Explain that Radium-223 Scenario 3 Neurological - increased, Acute pain Draw digoxin/ CMP labs as ordered - Ineffective health maintenance Provide morphine John Duncan Room 302 Joyce Workman Room 303 Meds for new dx diabetes? Scenario #5 Call HCP Serum Potassium 4.2 mEq/L Self-actualization- Scenario 4 Electrolyte imbalance, risk for Start secondary IV Order a new clear Escort pt. Altered body image, risk for Ineffective Breathing Pattern: False Initiate IV Contact Social Services for a new consult Scenario 2 Scenario #3 2-hrs later, Mr. Duncan is asked how frequent his stools have been today. Impaired Physical Mobility: True Scenario #3 Educate pt. Pain - increased Provide emotional support HCP orders 1.) All 5 toes on the right foot are necrotic, absent pedal pulses, skin cold to touch, appearance dry, cracked and black up to mid-calf. Robert Sturgess 16. Reinforce to the pt. Knowledge deficit: False Check I/O for possible dehydration Use therapeutic Fall, risk for Scenario 3 Contact power of attorney Scenario 2 Notify doctor Document results/findings Monitor neurovascular status assessing skin color, temp, sensation and pulses above amputation. Contact HCP Complete skin assessment Documents all interactions why you are doing Complete initial Ineffective breathing pattern, Scenario #1 Safety- Notify family Scenario #4 Perform circulatory evaluation Scenario 1 Allow husband Fall Risk - increased Decisional comfort Notify HCP Begin list of medications and time/dose given. -Sit at the patient's eye level and ensure they can see your lip movement and facial expression Contact Social Services 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 w/ a pillow at his operative site. Retake VS Scenario #5 She was asymptomatic upon arrival. Scenario #4 Scenario 5 Use therapeutic Wash hands and don gloves Sleep deprivation: False Scenario 3 Julia Monroe 14. Consult social services Discuss options - Anxiety - Pain - increased Julia Monroe What are your views, please? Draw stat D-Dimer Educate pt Initiate I&O Scenario #5 Scenario #3 Ask nursing manager, Acute pain Scenario 1 Document, - Educational Needs - increased -Ask the patient`s husband if he has a copy of the updated advance directive -Assure patient that she is safe in the hospital, and you will not leave her Notify Dr for new pain medications 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. Reassess respiratory Pre-medicate for pain w/ prescribed medication Inform the pt. Restart IV Administer ABX Scenario 5 Concepts of Nursing IV 100% (2) Deanna Concept Map Assignment 1. Pain - increased Risk for constipation: False - Fall Risk - increased Discuss the policy Notify HCP Inform his partner that everything is being done to keep him comfortable. Scenario 1 Ensure cardio pads Surgery called to the unit the Ms. Pittman is scheduled at 1300 for a BKA. Start and IV Complete assessment Mary Barkley Remind staff that Universal Precautions are practiced at this hospital for all pts regardless of known ID's. to Pain - normal Deanna Concept Map Assignment 1. Deficient knowledge Serum Sodium 142 mEq/L Social isolation, Scenario #1 Use therapeutic communication/active listening Apply restraint Fall Risk: Normal acuity - Impaired tissue perfusion PsychologicL Needs - increased Nausea: False Obtain VS Report Mr. Martinez's emotional distress to case management Wash/glove hands Reassure Mr. Jones Evaluation pt after consult Assess last medication Reorient pt to person, place & time Fall, Risk for: True Contact HCP if pt status does not improve Medicate Notify Dr of change in condition in particular; unproductive cough and low-grade fever. Verify soft, low sodium Mrs. Hatcher appears restless, diaphoretic and calls the nurse for help. Impaired skin integrity: True Offer to the family Disturbed body image: True change diet to HH 6.) Assure pt. Scenario #4 Pain: Increased acuity The plan is to discharge Ms. Yu back to her assisted living facility. jessdevan. -Ensure pathway is clear Inform pt. Wash hands upon entering the room Complete full assessment What should be included in the A. Perform Instruct pt not to get out of bed w/o assistance Administer pain medications Swift River- Pediatrics. Psychological Needs: Increased acuity

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