swift river new pt 1 exam guide 2024

Keaton Henderson - Educational needs increased Fall risk increased Health change increased Pain level increased Psychological needs normal Neurological normal Acute pain Bleeding, risk for Impaired comfort Fall risk Introduce yourself to pt and inquire about patient's pain and comfort Take his V/S Auscultate lung sounds and inspect wound site inspect pleurovac Mark the drainage level of the pleurovac Assess his vital signs Assess patient's chest tube insertion site Check his pleurovac Administer pain medication Encourage patient to use IS Assess for mediastrinal shift or tracheal deviation Administer 100% oxygen Auscultate lung sounds Assess pleurovac patency Call for RR Explain to the pt the plan of care, and that the procedure may be painful. Obtain 16 gauge angiocath and prep the second midline intercostal space on the right side Set up sterile thoracic tray for chest tube insertion Obtain and fill a new pleurovac and Vaseline-gauze dressing Assist w/ new chest tube insertion Assess V/S Auscultate all lung fields Complete stat portable chest xr Inspect insertion site and ensure no leakage of blod/air