Swift River Med-
Surg
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Terms in this set (18)
,Carlos Educational Needs: Increased
Mancia Fall Risk: Increased
Health Change: Increased
Carlos Pain Level: Normal
Mancia, 48yr- Psychological Needs:
old, Spanish Increased
speaking Sensorium: Normal
migrant
worker with Physiological-
no known Dysfunctional Gastrointestinal
past medical Motility: False
Hx. r/o Electrolyte Imbalance: False
Tuberculosis. Fatigue: True
Vital signs - Impaired Gas Exchange: True
Temp 99.1, BP Impaired Mobility: False
124/62, P 77, Ineffective Airway Clearance:
RR 20, SaO2 True
91%. Airborne
Isolation. Esteem-
Neuro WNL. Decisional Conflict: False
Skin moist, Noncompliance: True
respiratory
bilateral Safety-
wheezes and Anxiety: True
rhonchi. Deficient Knowledge: True
Blood-tinged Fall, Risk for: True
mucous, Fear: True
productive Hypothermia: False
cough. Diet Impaired Home Maintenance
as tolerated. Management: False
IV
maintenance Self-Actualization-
fluids with D5 Readiness for Self-Care
1/4 NS @ 150 Enhancement: True
ml/hr X 3 then Spiritual Distress: False
,reduce rate
to 75 ml/hr. Love and Belonging-
Expresses Chronic Sorrow: False
fatigue, fear, Social Isolation, Risk for: True
concern, and
desire for
recovery.
Need
frequent
reminder to
stay in room
and maintain
mask
precautions.
If
family/visitors
come, will
need
education to
airborne
precautions.
Spanish
interpreter
available at
extension
61178. Dr.
Rondeau
, Jody Rush Educational Needs: Increased
Fall Risk: Increased
Jody Rush, 20 Health Change: Increased
y/o female, Neurological: Increased
admitted for Pain Level: Normal
right femur Psychological Needs: Normal
fracture
status post Physiological-
skiing Acute Pain: True
accident. She Bleeding, Risk for: True
is in a traction Impaired Mobility, Risk for:
splint, and True
will be going Nausea: True
for surgical
repair today. Safety-
Vital signs are Deficient Knowledge: True
BP 120/62 P Grieving: False
88 R 20 T 98.9 Peripheral Neurovascular
F, 37.2 C, Dysfunction: False
PaO2 99. She
has been in a
lot of pain,
and has been
receiving 25
mcg IVP, q2
hours
Fentanyl for
pain. She was
nauseated
after her last
Fentanyl
dose, and the
Dr. Ordered
an additional
4mg IVP,
Surg
Leave the first rating
Save
Terms in this set (18)
,Carlos Educational Needs: Increased
Mancia Fall Risk: Increased
Health Change: Increased
Carlos Pain Level: Normal
Mancia, 48yr- Psychological Needs:
old, Spanish Increased
speaking Sensorium: Normal
migrant
worker with Physiological-
no known Dysfunctional Gastrointestinal
past medical Motility: False
Hx. r/o Electrolyte Imbalance: False
Tuberculosis. Fatigue: True
Vital signs - Impaired Gas Exchange: True
Temp 99.1, BP Impaired Mobility: False
124/62, P 77, Ineffective Airway Clearance:
RR 20, SaO2 True
91%. Airborne
Isolation. Esteem-
Neuro WNL. Decisional Conflict: False
Skin moist, Noncompliance: True
respiratory
bilateral Safety-
wheezes and Anxiety: True
rhonchi. Deficient Knowledge: True
Blood-tinged Fall, Risk for: True
mucous, Fear: True
productive Hypothermia: False
cough. Diet Impaired Home Maintenance
as tolerated. Management: False
IV
maintenance Self-Actualization-
fluids with D5 Readiness for Self-Care
1/4 NS @ 150 Enhancement: True
ml/hr X 3 then Spiritual Distress: False
,reduce rate
to 75 ml/hr. Love and Belonging-
Expresses Chronic Sorrow: False
fatigue, fear, Social Isolation, Risk for: True
concern, and
desire for
recovery.
Need
frequent
reminder to
stay in room
and maintain
mask
precautions.
If
family/visitors
come, will
need
education to
airborne
precautions.
Spanish
interpreter
available at
extension
61178. Dr.
Rondeau
, Jody Rush Educational Needs: Increased
Fall Risk: Increased
Jody Rush, 20 Health Change: Increased
y/o female, Neurological: Increased
admitted for Pain Level: Normal
right femur Psychological Needs: Normal
fracture
status post Physiological-
skiing Acute Pain: True
accident. She Bleeding, Risk for: True
is in a traction Impaired Mobility, Risk for:
splint, and True
will be going Nausea: True
for surgical
repair today. Safety-
Vital signs are Deficient Knowledge: True
BP 120/62 P Grieving: False
88 R 20 T 98.9 Peripheral Neurovascular
F, 37.2 C, Dysfunction: False
PaO2 99. She
has been in a
lot of pain,
and has been
receiving 25
mcg IVP, q2
hours
Fentanyl for
pain. She was
nauseated
after her last
Fentanyl
dose, and the
Dr. Ordered
an additional
4mg IVP,
