Linda Pittmon - CORRECT ANSWER EN - increased
FR - increased
HC - increased
N - increased
PL - normal
PN - normal
-Disturbed body image
-Ineffective health maintenance
-Risk for malnutrition
-Impaired tissue i
...
Linda Pittmon - CORRECT ANSWER EN - increased
FR - increased
HC - increased
N - increased
PL - normal
PN - normal
-Disturbed body image
-Ineffective health maintenance
-Risk for malnutrition
-Impaired tissue integrity
-Risk for physical injury
-Self-care deficit
1. Wash hands and don gloves.
2. Obtain blood for laboratory testing and blood culture # 1.
3. Obtain blood from secondary site for blood culture #2.
4. Initiate IV fluids to peripheral site.
5. Administer levofloxacin as ordered.
1. Ask the patient if she knows where the syringe came from and what was in the syringe.
2. Assess the vital signs and perform a neurological focused assessment.
3. Place the syringe in a biohazard bag and place a patient identification label on bag.
4. Notify the charge nurse and house supervisor of the syringe found in bed.
5. Notify the physician of assessment findings and await further orders.
1. Assess vital signs and perform head to toe assessment.
2. Therapeutic communication with patient.
3. Call Healthcare Provider for change in health status and receive orders for anxiety medication.
4. Prescribed medication for anxiety must be administered.
5. Assess for therapeutic response to medications.
1. Ask Mrs. Pittmon if she remembers the conversation with the physician and if she has any further questions that need to be addressed.
2. Perform pre op checklist.
3. Ensure signed consents are on the chart.
4. Ensure type and cross match for blood products is complete and results are in electronic medical record.
5. Have IV antibiotics available to administer when surgery calls for the patient to be transferred to pre op area.
1. Pre-medicate for pain with prescribed medication.
2. Don clean gloves to remove old dressing.
3. Monitor neurovascular status assessing skin color, temperature, sensation, pulses above amputation.
4. Don 2nd set of clean gloves to provide stump care. The wound has been sutured and is not an open wound/stump.
5. Elevate stump and rewrap with a dry clean dressing.Assess the vital signs and perform a neurological focused assessment.
Kenny Barret - CORRECT ANSWER EN - increased
FR - increased
HC - increased
PL - increased
PN - normal
S - normal
-Acute Pain
-Deficient knowledge
-Fall risk
1. Perform hand hygiene.
2. Re-assess blood pressure and pulse. BP is 190/110, pulse is 86.
3. Evaluate patients understanding of the medication and provide education.
4. Administer the medication.
5. Document on the MAR and education in the chart.
1. Retake vital signs (BP is 110/70, pulse is 94).
2. Instruct patient not to get out of bed without assistance.
3. Perform comfort measures.
4. Request CNA to remain with patient.
5. Notify the healthcare provider using SBAR.
1. Patient Kenny Barrett is nauseated and complains of dizziness when they sit up.
2. Patient was admitted yesterday afternoon with hypertension, BP 178/90, pulse 88, hypertension was undiagnosed and was started on Atenolol 50mg, once a day. This is his second dose. IV 20 gauge, left forearm NS 125ml/hr.
3. Current vital signs are BP:110/70, Pulse: 94. Patient is pale, dizzy, and nauseated.
4. Request possible change in medication and more frequent vital signs.
1. Take vital signs now and Q4 hours.
2. Maintain strict I&O.
3. 500 mL normal saline bolus.
4. Hold next dose of Atenolol if BP is <130/80.
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