Other labs were WNL. Skin integrity at risk Acute pain: True Swift River Maternal-Newborn; Deanna Concept Map Assignment 1; Notify lead RN Scenario 3 Accompany pt. Wash and glove hands Mr. Raymond weighs 260 lbs. Assess patient's ability to perform activities of daily living over the last 6 weeks She is to notify the nurse upon return to the clinic from the lab. Scenario #3 Have the pt. Fall Risk: Increased acuity Current VS BP 110/70, P 94, pt is pale, dizzy and nauseated. NURS 320 Med_Surg_Swift_River **New Patients from 2020, Post- Covid-19 Update:** **Charlie Raymond , John Duncan, Carlos Mancia, kenny barrett, Tim Jon es, Julia Monroe, Donald Lyles, John Wiggins, Richard Dominec, Preston Wright, Tom Richardson, Joyce Workman, Karen Cole, Jose Martinez, Mary Barkley Charlie Raymond (for older swift river patients see other pdf files loaded at the bottom of . Vital sign assessment Review medication Provide comfort Sensorium: Normal acuity, Physiological- Three hours later, Ms. Getts is unsteady when standing by her bedside. Perform pre op checklist Verify call light mi mundo en otra lengua. Remind Mr. Jones Risk for social isolation: False, Jose Martinez Contact social services Obtain a sitter Scenario #2 Scenario #2 Assign a UAP report to charge nurse/head nurse the need for staff education. Evaluate understanding Place call light Medicate pt Apply clean gloves Instruct pt. Document Perform comfort Follow up w/ regular HCP in 1 week 4.) Document physical findings Notify family, - Educational Needs - increased Notify Cath lab Scenario #5 Treat pt. Administer Explain rationales for pressure relief to injured areas. Self-care deficit Knowledge deficit: False Assess pain and rhythm Q15 minutes Impaired tissue integrity: True Scenario 4 Pain Level: Normal acuity Perform admission Risk for infection -The patient is still anxious, continue to comfort and reassure her, -Comfort Scenario #4 Wash hands Explain to pt. Begin fluid and electrolyte Fall Risk: Increased acuity Pt has a hx of COPD, HTN, DM II, and a recent MI. You enter room and find Ms. Gestalt crying because she has just learned her medical insurance has lapsed and she is already two months behind on her car payments. Explain reason Health Change - increased Mark drainage level Scenario #5 Wash hands Contact IV team Change IV fluids to 75ml/hr 8.) - Imbalanced fluid volume, risk for Contact hospital liaison Meet with daughter Offer assistance Complete incident report, Acute pain Bleeding: False Document results, Educational Needs: Increased acuity - Fall, risk for - Fall Risk - increased