Swift River Medical Surgical
Study online at https://quizlet.com/_dotbhc
Ann Rails 38 years old, c/o back pain,
non-significant past medical history. No
known allergies (NKA). Vital signs -BP
124/82, Temp 98.2, P 84, RR 22, SaO2
96%. Pain and numbness in legs for one Fall risk
week. Abnormal left leg weakness, gait Health change
unsteady, 5/10 on numeric pain scale. Pain level
Neuro WNL, except leg pain upon move- Educational Needs Psychological Needs
ment. Activity as tolerated with assis-
tance. D/C plan- decrease pain and re-
store normal gait. Regular diet. Dr. Sucu-
lo
Arthur Thomason 56-year-old MVA vic-
tim, fourth day post op with a splenecto-
my and femur repair. He is experiencing
new onset of shortness of breath and
has a nasal cannula with 2L of Oxygen
in place. He is restless with slight confu-
sion but is easily orientated with attempts
from nurse. Temperature spiked during
Educational needs
the night to 102.4, BP now 146/94 which
Health change
is slightly elevated, respirations at 30
LOC
bpm and slightly labored, heart rate 102
Pain level
versus 84 from last night shift. Skin cool
Psychological needs
to touch and appears pale. His cough-
Safety
ing, to clear his airway, appears ineffec-
tive. Recent chest X-ray shows diffuse
bilateral interstitial infiltrates in all lobes.
Recent blood gases demonstrate falling
PaO2 (hypoxemia) and increasing CO2
(Hypercapnia). Mr. Thomason is anxious
and is obviously worsened from the shift
before in overall condition.
Calvin Umbyuma Mr. Umbyuma is a 42
y/o male who has been admitted for com-
plaints of shortness of breath with pleu-
ritic chest pain. He was diagnosed with
HIV positive antibodies over a year ago.
, Swift River Medical Surgical
Study online at https://quizlet.com/_dotbhc
He has recently been traveling back to
his home country of Kenya to visit his
sick mother. He received traditional med-
ical treatment at his village. His temp is
100.9 F, 38.3 C, R 22, P92, BP 152/89 Educational needs
PaO2 91%. Inflammatory markers - Ery- Health change
throcyte Sedimentation Rate (ESR) and Pain level
C-Reactive Protein (CRP) are elevated
at 78.9 mm/h and 67.2 mg/L. He has
been placed in a room at the end of the
hall.
Cameron Daniels just turned 18 y/o. She
is being admitted from the ER with a
diagnosis of pelvic inflammatory disease
(PID). She has heavy vaginal discharge
with an unpleasant odor. She is com-
plaining of abdominal pain and looks
Educational
pale. She was seen by OBGYN in the
Health change
ER and a culture was sent to the lab
Pain level
for Chlamydia and Neisseria Gonorrhea.
Fall risk
She was a very difficult IV start and has
a 23g saline lock (SL) in her right hand.
They have ordered a liter bolus of LR,
but it is running very slowly and the IV is
positional. VS BP 96/58, P 116, R 18, T
101.2 PaO2 98%.
Acute discomfort
Higher numbered acuities are at most Alteration in mobility
risk. Knowledge deficit
Cameron Daniels, acuity 3, room 304 Potential falls
Potential for infection Nausea
Alteration in comfort
Alteration in gas exchange
Higher numbered acuities are at most Ineffectual airway clearance
risk. Potential for shock
Arthur Thomaston, acuity 3, room 302 Prolonged confusion
Anxiety/fear
Potential for failure to thrive
Higher numbered acuities are at most
risk.
Calvin Umbyuma, acuity 2, room 303
Study online at https://quizlet.com/_dotbhc
Ann Rails 38 years old, c/o back pain,
non-significant past medical history. No
known allergies (NKA). Vital signs -BP
124/82, Temp 98.2, P 84, RR 22, SaO2
96%. Pain and numbness in legs for one Fall risk
week. Abnormal left leg weakness, gait Health change
unsteady, 5/10 on numeric pain scale. Pain level
Neuro WNL, except leg pain upon move- Educational Needs Psychological Needs
ment. Activity as tolerated with assis-
tance. D/C plan- decrease pain and re-
store normal gait. Regular diet. Dr. Sucu-
lo
Arthur Thomason 56-year-old MVA vic-
tim, fourth day post op with a splenecto-
my and femur repair. He is experiencing
new onset of shortness of breath and
has a nasal cannula with 2L of Oxygen
in place. He is restless with slight confu-
sion but is easily orientated with attempts
from nurse. Temperature spiked during
Educational needs
the night to 102.4, BP now 146/94 which
Health change
is slightly elevated, respirations at 30
LOC
bpm and slightly labored, heart rate 102
Pain level
versus 84 from last night shift. Skin cool
Psychological needs
to touch and appears pale. His cough-
Safety
ing, to clear his airway, appears ineffec-
tive. Recent chest X-ray shows diffuse
bilateral interstitial infiltrates in all lobes.
Recent blood gases demonstrate falling
PaO2 (hypoxemia) and increasing CO2
(Hypercapnia). Mr. Thomason is anxious
and is obviously worsened from the shift
before in overall condition.
Calvin Umbyuma Mr. Umbyuma is a 42
y/o male who has been admitted for com-
plaints of shortness of breath with pleu-
ritic chest pain. He was diagnosed with
HIV positive antibodies over a year ago.
, Swift River Medical Surgical
Study online at https://quizlet.com/_dotbhc
He has recently been traveling back to
his home country of Kenya to visit his
sick mother. He received traditional med-
ical treatment at his village. His temp is
100.9 F, 38.3 C, R 22, P92, BP 152/89 Educational needs
PaO2 91%. Inflammatory markers - Ery- Health change
throcyte Sedimentation Rate (ESR) and Pain level
C-Reactive Protein (CRP) are elevated
at 78.9 mm/h and 67.2 mg/L. He has
been placed in a room at the end of the
hall.
Cameron Daniels just turned 18 y/o. She
is being admitted from the ER with a
diagnosis of pelvic inflammatory disease
(PID). She has heavy vaginal discharge
with an unpleasant odor. She is com-
plaining of abdominal pain and looks
Educational
pale. She was seen by OBGYN in the
Health change
ER and a culture was sent to the lab
Pain level
for Chlamydia and Neisseria Gonorrhea.
Fall risk
She was a very difficult IV start and has
a 23g saline lock (SL) in her right hand.
They have ordered a liter bolus of LR,
but it is running very slowly and the IV is
positional. VS BP 96/58, P 116, R 18, T
101.2 PaO2 98%.
Acute discomfort
Higher numbered acuities are at most Alteration in mobility
risk. Knowledge deficit
Cameron Daniels, acuity 3, room 304 Potential falls
Potential for infection Nausea
Alteration in comfort
Alteration in gas exchange
Higher numbered acuities are at most Ineffectual airway clearance
risk. Potential for shock
Arthur Thomaston, acuity 3, room 302 Prolonged confusion
Anxiety/fear
Potential for failure to thrive
Higher numbered acuities are at most
risk.
Calvin Umbyuma, acuity 2, room 303
