Scenario 2 Review plan of action Anxiety: True -Ask the patient`s husband if he has a copy of the updated advance directive Scenario #3 Clean wound the sterile saline, apply triple abx ointment per HCP order. Her husband who is present stats, "I thought it was just a lumpectomy she was having this morning." Do not probe further Ask open-ended Evaluate understanding Apply new dressing Fall, Risk for: False Scenario #5 Psychological Needs: Normal acuity, Physiological Health Change: Increased acuity Use therapeutic Kenny Barrett 6. Notify the HCP of absence of Advanced Directive and the families request to intubate. Remove old dressing verbalize, Educational - increased Ethical issues for practice? Evaluation pt. Medicate Pain - increased Place pt. Describe the experimental evidence that DNA is the hereditary material of bacteriophages. -Because of the patient's long bone fracture, you are aware that a Pulmonary embolus (PE) is a possibility Impaired home maintenance management: False Chronic sorrow: False Notify HCP Remind CODE Full assessment Document results The patient`s vital signs, are BP: 152/90, P: 101, R: 28, T: 99.1 F, 37.23, hyperglycemia. -Safety - Noncompliance Wash hands Change dressing Med-Surg SR. 83 terms. mary_heath32. She also takes Metformin to control her Type 2 Diabetes. Ask the pt about any metal in or on her body Fall Risk - increased Acute Pain: True Scenario #3 Educate patient regarding patient care Past medical history includes hyperlipidemia, current elevated triglycerides, and a history of 1 pack a day smoker for the past 20 years. Pain - increased Fall Risk: True Discuss w/ pt identified home health needs Serum Sodium 142 mEq/L Scenario 3 -Inform the patient that we cannot honor her current advance directive He is still unresponsive. Hold next dose Impaired tissue integrity: True 7/3/2014 1 0 0 0 7/3/2014 100 0 0 0 0 0 1 1 0 0. nur104 Swift river scenarios Exams study guides . Educate the family regarding intervention and support for Ms. Horton Place call light and check bed for safety Reassess respiratory acquire daily weight and food intake -Gas exchange -Determine cognition by asking questions to determine if she knows who, where, and what happened -The patient is still anxious, continue to comfort and reassure her, -Comfort You determine to apply the restraint now. Scenario 3 Neurological: Increased acuity Obtain translator Monitor neurovascular status assessing skin color, temp, sensation and pulses above amputation. Notify doctor (for possible removal) Educate pt Mr. Wright reports pain 6/10, and is requesting medication prior to dressing change Risk for post trauma syndrome: True Scenario #4 Joyce Workman Room 302 Joyce Workman, a 42-year-old female who presents to the Diabetes Clinic with a new diagnosis of type II diabetes. Altered body image Full assessment Provide medical hx including medication hx and allergies Scenario #5 Psychological Needs: Normal acuity, Physiological- Check patency Perform full assessment Assess MR. Martinez's willingness Scenario #3 Wash/glove hands Fluid & electrolytes Assess for bowel Pain - increased Scenario #5 Provide for physical ECG was unremarkable. Insert new IV above prior site or opposite limb Document Document results/findings She puts her call light and asks to see a RN. Mr. Mancia is a non-English speaking pt and is fearful of being discovered as an illegal immigrant. Post CVA, he has developed some aphasia and is having difficulty with verbal communication. Contact Assisted Living Facility to see if pt has an advanced directive in place declining intubation. Psychological Needs - normal, Bleeding, risk for
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