Swift River - Med Surg(2022)completed

Sarah Kathryn Horton phase one: educational needs - increased fall risk - increased health change - increased pain level - increased psychological needs - increased sensorium - normal phase two: acute pain anxiety disturbed personal identity impaired physical mobility impaired skin integrity risk for post trauma syndrome alteration of protective mechanisms phase three: scenario 1 - - wash hands prior to entering the room - assess respiratory status - do not disturb the patient - reduce stimuli in patient room - document all findings scenario 2 - - wash hands prior to entering the room - assess Ms. Horton's orientation - medicate patient - attempt deescalation strategies - document all findings scenario 3 - - gather supplies needed for dressing change - wash hands upon entering the room - explain procedure to Ms. Horton - provide Morphine Sulfate 4 mg IV - perform dressing change scenario 4 - - educate Ms. Horton that paroxetine is to be taken as ordered - reinforce past coping mechanisms - educate family regarding active listening and open communication - educate family regarding intervention and support for Ms. Horton - document all interactions scenario 5 - - assess Ms. Horton's orientation status - use therapeutic communication to reorient and provide reassurance - assist Ms. Horton back into the wheelchair - escort patient to ER for a physical and psychological evaluation - provide report to ER nurse Charlie Raymond phase one: educational needs - increased fall risk - increased health change - increased neurological - normal pain level - normal psychological needs - normal phase two: death anxiety impaired gas exchange ineffective breathing pattern phase three: scenario 1 - scenario 2 - - don appropriate PPE - change to simple O2 face mask - perform focused respiratory assessment - notify respiratory therapist to begin treatment - notify family to self isolate for 14 days scenario 3 - - use therapeutic communication to explain necessary procedure - position patient properly - create sterile field with foley kit on bedside table and don sterile gloves - instruct Lucy to assist in maintaining patient position and field sterility - insert foley catheter scenario 4 - - make sure O2 mask is secure and free of sputum - ensure patient is in fowler's position - check foley catheter to make sure it is not obstructed - notify rapid response team - provide initial report and assist RRT scenario 5 - - Mr. Raymond, COVID 19 positive, in severe respiratory distress, rapid response called - patient has history of COPD, HTN, diabetes, a recent MI. Patient received Furosemide, Lasix 20 mg IVP x2, on Claforan Q4 and on sliding scale insulin - Intubated by RRT, BP 88/58, P 110, T 101.2, SaO2 94%, ABGs are pending. Foley catheter in place - Recommend patient be transferred to ICU - Accompany patient to ICU and give report to receiving nurse