NURS 3330 TIM JONES ROOM 308 MED SURG (ALL EVALUATIONS)

Tim Jones Room 308 Tim Jones, 82 -year old male patient of Dr. Diggs just arrived this morning from the local nursing home. He was confused upon arrival. During the initial assessment, fresh and various stages of brui ...

Tim Jones Room 308 Tim Jones, 82 -year old male patient of Dr. Diggs just arrived this morning from the local nursing home. He was confused upon arrival. During the initial assessment, fresh and various stages of bruise healing were noted to his shoulders, lower back, ribs, and thighs. Admitted to Med-Surg for new onset confusion. Mr. Jones is guarded and has facial grimacing anytime someone reaches toward him or touches him. He does moan when rolled. You responded correctly to 6 out of 6 evaluations: Category Your response Explanation Educational Needs Increased acuity Mr. Jones needs reassurance that he is in a safe place and that the staff want to help him. He also needs education on pain medication. Fall Risk Increased acuity Mr. Jones is 82 years old and confused. Health change Increased acuity New onset bruising as well as various stages of bruise healing noted. Neurological Increased acuity Patient is experiencing new onset of confusion. Category Your response Explanation Pain level Increased acuity Mr. Jones moans when rolled and has several wounds. Psychological Needs Increased acuity Mr. Jones is guarded and grimaces anytime someone reaches toward him. You correctly diagnosed 7 out of 7 options: Physiological Description Your Response Explanation Decisional conflict False Scenario does not support this diagnosis. Defensive coping True Related to fear of abuse as a result of onset bruising and facial grimacing. Disturbed sleep pattern False Scenario does not support this diagnosis. Ineffective health maintenance True Patient is unable to protect himself from harm. Risk for spiritual distress False Scenario does not support this diagnosis. Safety Description Your Response Explanation Isolation precautions False Scenario does not support this diagnosis. Risk for injury at home True Related to presenting with different stages of bruising while in nursing home. Scenario 1 You correctly ordered 5 out of 5 act