Swift River Medical-Surgical Exam Guide 2024

Ann Rails - Educational - Increased Fall Risk - Increased Health Change - Increased Pain - Increased Psychological Needs - Normal Sensorium - Normal Ann Rails - Acute pain Impaired comfort Impaired mobility Disturbed sensory perception Fall, risk for Peripheral neurovascular dysfunction Ann Rails - Scenario #1 Use therapeutic Educate pt. Evaluate pt. learning Place call light Document Scenario #2 Wash and glove hands Assess Provide comfort measures Notify doctor Document Scenario #3 Listen to pt. concerns Reassure pt. of options Notify lead nurse/doctor Contact Social Services Document Scenario #4 Wash and glove hands Visual assessment Do not disturb Verify Call Light Document Scenario #5 Assess for bowel sounds Encourage fluids/fiber/ambulation Evaluate pt. understanding Attain fluids/fiber diet Document Arthur Thomason - Educational - increased Health change - increased LOC - increased Pain - increased Psychological needs - increased Safety - increased Arthur Thomason - Impaired confort Impaired gas exchange Ineffective airway clearance Shock, risk for Anxiety/fear Failure to thrive, risk for Arthur Thomason - Scenario #1 Assess Replace O2 Use therapeutic Notify Dr. and charge nurse Scenario #2 Remind physician Explain to physician Assist physician Obtain recent Reassure pt. Scenario #3 Tap pt. Elevate HOB Call rapid response Start secondary Remain with pt. Scenario #4 Provide verbal report Emergency intubation Assume role Obtain pt. record Provide information Scenario #5 You explain that his condition You explain that he is receiving You have them remain with you You escort them with you You call his doctor Calvin Umbyuma - Educational - increased Fall Risk - normal Health Change - increased Pain - increased Psychological needs - normal Neurological - normal Calvin Umbyuma - Acute pain Deficient knowledge Calvin Umbyuma - Scenario #1 Place on respiratory isolation Ask Mr. U Obtain blood cultures Start IV Collect sputum culture Scenario#2 Wash hand, don PPE Explain to the visitor Respiratory assessment Explain to Mr. U Place signage on door Scenario #3 Ask pt. what he knows Ask pt. what his mother's Educate pt. Evaluate effectiveness Report findings Scenario #4 Pt. teaching Contact respiratory therapy Chest x-ray