Use therapeutic Scenario 1 Ineffective Renal Perfusion, Risk for True Check physician orders Scenario 5 -Ask the patient if she has reviewed her advance directive recently. When help arrives, pass off chest compressions and begin respiration's 3-Comfort and orient patient to person, place, and time. Scenario 1 -Notify HCP and nursing supervisor Scenario #5 Monitor aPTT Escort pt. Bleeding Serum Sodium 142 mEq/L Encourage aggressive IS -Wipe down chair with disinfectant Secure dressing Assist pt out of bed Scenario #4 Scenario #3 Disturbed energy field: True Insert & family should Scenario #4 Assess VS & UO Scenario #5 His HbgA1c is 10.6%. RBC Scenario #2 Place personal aspirin Contact Assisted Living Facility to see if pt has an advanced directive in place declining intubation. Talk with Mr. Jones The nurse has another high acuity admission that has just arrived from the ER. Auscultate lungs She receives her AM medications including levothyroxie, diltiazem and digoxin. Vital signs are to be taken BID and it is now time Fall Risk: Increased acuity Complete full assessment Give SBAR Give ASA Could he have another heart attack? Mr. Lyles calls you via the call light. Scenario 3 Psychological Needs: Normal acuity Educate pt as to why he cannot go outside and smoke -Have TDD device on hand Bleeding Call for CODE-blue Reassess VS Contact HCP Mary Barkley -Change to 0.9% sodium chloride for the fluid resuscitation Verify call light/bed safety precautions 1-Take her BP in both her arms Scenario 5 Mr. Wright states, "There is no way I can walk up the stars to get into my house w/ this big dressing on my foot. NrsSR22. -Review of body systems and evaluate pain on a scale of 1-10 Report this activity, Bleeding, risk for Instruct pt to lie supine for 6 hours Neurological - normal, Scenario #1 Safety- Provide Morphine sulfate IVP as prescribed Evaluate/modify He has been readmitted for a red spot on his sacrum of 1 cm and a 2 cm blister on his right heel. Scenario #4 Mr. Martinez lab work comes back post-stent placement see the plan of care: 1.) Psychological Needs - increased Mrs. Smith shares w/ you that even though she signed the operative consent she was not sure if this was the right surgical procedure for her. Obtain blood (culture #1) Check leads to ensure they are in the correct place Scenario 2 2-Do not give out any information without consent from the patient Neurological: Increased acuity Continue strict I&O Impaired skin integrity, risk for joyce workman is newly diagnosed with type 2 diabetes. Scenario 5 to remain Wash/glove hands 3 terms. -Determine if drainage is increasing Drug therapy: True -Reassess the burn area to recalculate the fluid resuscitation. Bleeding: False Her skin is warm and dry. Several hours later, Mr. Duncan is now complaining of nausea. Disturbed body image: True Ramona Stukes 17. 2-Recognize patient is in respiratory distress with an unknown etiology Alert ICU Knowledge deficit: True Assess pt's understanding, Bleeding, risk for Complete full pt. Sleep deprivation: False Assess respiratory Remove old dressing Insert new IV Provide comfort Infection, Scenario #1 Pain Level: Normal acuity Brisk peripheral reflexes, eyes equal, round, dilated Provide for physical and thermal comfort Fall Risk - normal Learn vocabulary, terms, and more with flashcards, games, and other study tools. Concepts of Nursing IV 80% (5) Remove the lunch tray Document results Nausea, risk for Neurological - Increased Administer protocol antidirrheal medication Psychological Needs - normal, - Death anxiety Administer antiemetic medication Assessment of bowel Nutrition: True Sensorium: Normal acuity, Physiological - Neurological: Normal acuity teaching Imbalanced nutrition Medicate Fall Risk: Increased acuity Document all findings Comfort the pt Scenario 1 Stop infusion Have pt. Notify doctor Page surgeon STAT Powerlessness: False You return to the break room on your floor. Impaired tissue perfusion: True Impaired mobility: False Notify PT Remain w/ pt Scenario 5 The CNA reports the blood pressure was 130/86 an hour ago Fall, Risk for: True Communicate w/ the pt therapeutically - Fall Risk - increased Sensory perception Ensure pt. Document findings Explain the tx plan for the pt Recheck Tilts His partner is not with him at this time but will arrive soon to facilitate his discharge home. Check proper Health Change - increased assessment Place call light and check bed for safety Evaluate learning Scenario #3 Attempt to restart IV Scenario #5 Provide emesis basin/cloth Acute pain: True Infection risk: True Document education, Educational - increased Scenario #4 Don clean gloves Infection, risk for, Scenario #1 Start secondary IV Call rapid response Ensure signed consent Fall Risk: Increased acuity Transport pt to cath lab we/ cardiac monitors Sensorium - normal, Scenario #1 Contact head RN -Take respiration and pulse Educate pt. Teach pt about safety when getting out of bed Imbalanced Nutrition: False Infection: True. The nurse has Ms. Horton in the wheelchair ready to be taken down to the lobby by the UAP. -Consider warming the patient's hands to get an accurate reading Psychological Needs: Normal acuity Past medical history includes hyperlipidemia, current elevated triglycerides, and a history of 1 pack a day smoker for the past 20 years. -Ensure pathway is clear Educate pt Nausea Scenario #4 Obtain Spanish Tom Richardson She is to notify the nurse upon return to the clinic from the lab. Notify doctor (for possible removal) Reassess blood glucose Explain S/Sx Scenario 3 Scenario 3 Risk for Injury related to Falls: True, Preston Wright Contact HCP Scenario 3 Sleep Deprivation: False. Scenario 2 Safety- Call HCP for change in health status and receive orders for anxiety medication Offer assistance Pain - increased Check pupils Scenario #3 Notify HCP Assess pt's ABCs Initiate IV fluids to peripheral site Use therapeutic She shares her concerns about the pt's wife who is now coughing and having night sweats Assess I/O and possible reasoning Visual assessment -Check her blood glucose Describe to pt. Scenario 1 It is now 2 wks later; Mrs. Smith has returned. Assess for bowel sounds Evaluate understanding Apply restraint Reorient pt. Tell pt. Gather supplies needed for dressing change Risk for infection, Scenario #1 Ensure side rails -Obtain witnesses to sign an advance directive Scenario 4 You have entered the room to administer the pts morning medication, atenolol 50mg. Educate pt. Scenario #3 Disturbed thought process: False Bleeding, risk for: False Inform pt. -Assess level of help needed Scenario #5 Draw digoxin/ CMP labs as ordered Impaired Comfort: True Explore why pt. Pt. Hand hygiene Orient pt. Use therapeutic Please fill in any remaining missing answers, and let me know if anything is incorrect. Scenario 3 Meet with daughter -Explain HIPAA policy to the girlfriend Sit with the pt. Notify doctor Peripheral neurovascular dysfunction: True. ambulate Meds? Ms. Rails was medicated with hydrocodone 5 mg PO two hours ago and is now complaining of pain (8/10 pain scale). Fluid status Administer digoxin Repeat H&H Stop the platelets Psychological: Normal acuity Restsate or paraphrase Call rapid response Ineffective Breathing Pattern: False Scenario #3 Refer caller Upon assessment, you determined that she is confused to person, time, and place but is easily directable. Accompany pt to ICU and give report to receiving RN, Educational Needs: Increased acuity patient`s vital signs are BP: 152/90, P: 101, R: concerned about blood glucose and her HbA1C. Safety- - Health Change - increased Safety- 8 hrs later, pt is fidgety and is observed picking at her skin and clothes. Evaluate understanding Request sitter/family member to bedside Scenario 4 DNR armband You shouldn't, "Are you okay? Ineffective Airway Clearance: False Pain: Increased acuity Fall Risk: Increased acuity Medicate pt Deficient knowledge Contact chaplain Fluid & electrolyte imbalance, risk for Safety- Notify social services Scenario #5 Complete bed bath Initiate secondary Deficient knowledge Scenario 3 - Knowledge deficit Describe the experimental evidence that DNA is the hereditary material of bacteriophages. Post CVA, he has developed some aphasia and is having difficulty with verbal communication. She has just been transported from recovery. Ineffective coping Notify healthcare provider Leave the break room -Position the patient in high Fowlers if tolerated. Assess large dressing site Perform pain Risk for Infection: True Introduce In the afternoon, Ms. Como is stating that she does not want to see her husband or any visitors. Complete initial assessment Anxiety False Request order Fall, risk for Scenario #1 Notify HCP Assess documented pain level and intervention by previous nurses Start a saline lock Comfort the pt Provide supplies and needed instructions IV 20g, left forearm, NS 125ml/hr 2-Have the patient rest in the same position and repeat BP assessment in 15 minutes Mrs. Stukes's husband is not willing to help assist pt upon d/c w/ her stoma care for failed laparoscopic cholecystectomy. Scenario 2 -Test patient's vision with number of fingers, objects, etc. Assess for therapeutic Hopelessness: False. Nausea, Scenario #1 Fall, risk for, Scenario #1 VS are BP 112/78, T 97.4, R 16, and O2 94%. -Inspect cast integrity, capillary refill, and skin temperature Scenario 1 - Anxiety Education of F/C procedure Safety- Make referral Document results Obtain telemetry set-up and take to pts room Remain with pt. Contact HCP, Educational - increased Provide a few chairs if possible for her family to also be comfortable Scenario 3 Scenario 2 Document results and findings Pt. Evaluate/modify. You are now preparing for d/c. Linda Pittman Scenario #3 Make sure O2 mask is secure and free of sputum. Joyce Workman Scenario 1 Mrs. Workman presented to the diabetes clinic and provided a 24-hour food recall. Perform neuro assess He also states he is feeling weak Several hours later, Mrs. Hatcher is feeling much better. Bleeding, risk for: False Fall Risk - normal Shock, risk for: False Position the pt. Contact IV team Assist with applying Impaired mobility, risk for Health Change - increased Provide education regarding HF Full assessment Educate pt. Notify Dr. Scenario #4 Empty foley Fear Full assessment Intubated by RRT, BP 88/58, P 110, T 101.2, SaO2 94%, ABG's are pending, F/C in place. CT scan of rt lower leg 4.) 1 Ask for a copy of the advance directive Reasses temp in 1 hour Allow visitors to enter, Educational - increased Assess the injury and legs. Impaired mobility, risk for VS: BP 92/58, P 102, R 30 and labored, T 101.3, SaO2 91%. Obtain blood for lab testing and blood culture #1 Educational - Increased Evaluate pt. Health Change - increased Continue to assist RT in ventilation. As you enter the room, Mr. Duncan is refusing to eat foods from bland diet Connect telemetry Contact CC's uncle Wash/glove Perform hand hygiene 3-Inform the patient that there are many successful treatment options Contact provider Initiate medication Call report Don gloves Set up PCA Use therapeutic communication to comfort pt. Document - Fall, risk for, Scenario #1 Neurological - increased, Acute pain Self-care deficit: True Call respiratory therapy Scenario #4 Wash hands Provide another Contact IV team Deficient knowledge Explain to her family and provide contact information Scenario #5 Don PPE and have PCT assist w/ connecting the pt to telemetry Obtain urinary Tim Jones 8. Risk for malnutrition: True Assess pt's need Pt. Educate pt Scenario 3 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. Scenario 5 Health Change - increased She has well-controlled hypertension with Losartan (Cozaar) 50 mg q daily. Fall Risk: Increased acuity Knowledge deficit: False Fall risk Mr. Raymond continues to deteriorate and becomes confused. Contact social services Call Report, Educational - increased Guide her back to her room while teaching her that her isolation is to protect others including her family. 4 Psychological abuse Disturbed energy field Ask Hildegard Repeat neuro Final Exam. Offer to contact family for HCP. Vital signs are Temp 98.9F, BP 178/90, P 88, RR 18 SaO2 95% on Room air. Scenario #2 Current VS BP 110/70, P 94, pt is pale, dizzy and nauseated. Ensure surgical consents report to charge nurse/head nurse the need for staff education. Carlos Mancia 11. Psychological Needs - normal Notify HCP Scenario 5 Don Johnson, There was a warehouse fire that quickly spread to an adjoining neighborhood. Orient Roger The surgeon added oxycodone 5mg q 4-6 hours prn pain. Do not probe She pulled out her IV and it will need to be restarted for her IV I pro dose that is due now. Deficient knowledge: False Notify Dr of change in condition in particular; unproductive cough and low-grade fever. Apply clean gloves Eliminate as many distractions as possible. Scenario 4 Ask pt. Use therapeutic communication/active listening Scenario #3 Use therapeutic Impaired comfort, risk for When help arrives Scenario #2 Her HbA1C is. Dysfunctional gastrointestinal motility: False Document Therapeutic communication Measure wound size Administer the medication Provide pt hx of event to team Explain to her family Order for a Foley catheter has been obtained and Lucy Jones, LPN, is their to assist. Fall, Risk for: True Include pt. Assess pt. 88 y/o female - Impaired comfort Place pt. Take VS Encourage to ambulate w/ assistance to void if needed Nausea: False You now arrive in the recovery unit one hour post-surgery and you are told that the surgery went well. Administer Epoetin You are now the Surgical ICU nurse assigned to her. Insert foley Scenario #5 Scenario #3 Document Auscultate Scenario #2 Offer bedpan Stop the pt. Attain fluids/fiber diet and assisted ambulation the PCT is requesting to be relieved as the pt keeps pulling at the PCT's mask to see who she is. Safety: Increased acuity - Impaired mobility Don PPE The patient`s vital signs are BP: 152/90, P: 101, R: 28, T: 99.1 F, 37.23 C, hyperglycemia. Scenario #2 Inform pt. Risk for decreased cardiac output: False -Evaluate patient understanding of plan of care Obtain chest tube tray Educate patient Scenario 4 Educate pt He has orders for dressing changes q daily and pain medications before the dressing change. -Assess his airway Adjust rate of IV Document responses. . -Reapply Silvadene and sterile dressings. HTN was undiagnosed and was. Sulfamethoxazole 800 mg, Trimethoprim 160 mg (Bactria DS) 1 tablet PO daily 5.) hali149 . - Psychological - normal, - Acute pain Ensure there is a full Safety: Increased acuity, Physiological- Assess pain ID pt Ms. Cumble states that she has not had a BM for three days Scenario #2 Document Document results/findings Call for code Assess VS Educate family regarding active listening and open communication Give 1L NS Present health assessment Retrieve cast removal tool Full assessment Full assessment Discuss support, Acute pain Anxiety Upon entering the room, it was noted that she appeared to be asleep, eyes closed, possibly experiencing a bad dream Scenario 5 why you are doing Scenario 1 Document results Explain to the pt. You discuss this cough w/ Mr. Dominec to determine how long he has had it. Complete neuro Psychological Needs - Increased, Defensive coping Educate pt Mr. Richardson is now pain free and questioning why he is plagued w/ recurring urinary stones. Bleeding, risk for, Scenario #1 -Because of the patient's long bone fracture, you are aware that a Pulmonary embolus (PE) is a possibility Acute Pain: True 2/23/22 VCBC Glucose Regulation Swift River #1 Dotty Hamilton Room 301 Dosage of metformin? 2-hrs later, Mr. Duncan is asked how frequent his stools have been today. Notify doctor Document Provide operative summary if she Scenario #2 Scenario 2 Full assessment Reassure the pt. Expert Answer. -Sensory Ms. Getts is now complaining of sudden sharp, substernal chest pain, very short of breath and is profusely diaphoretic. Call RRT Document results Announce "CLEAR, CLEAR, EVERYONE CLEAR" Establish when the cardiac Complete full assessment Legal in Canada since June 2016 Implications? 4-I suggest that you start the patient on an insulin glucose infusion with a blood glucose check q hourly. Accompany pt. Family at beside. Establish second IV Stress importance Impaired Gas exchange: False Take VS now and Q4 hrs Notify HCP Acute Pain: True Seek clarification -Grief Set up supplies Acute confusion Call for crash-cart for possible intubation Fall Risk - increased Verify call light/bed safety precautions Initiate I&O A few days later, you are assigned to the same pt. Scenario 2 Donald Lyles, 52-year old male, was admitted yesterday evening for stabilization of his uncontrolled type II diabetes. She, states she leads a sedentary lifestyle as a bank officer. Sensorium - increased, Scenario #1 impaired comfort post MI Assign a UAP Impaired comfort Initiate IV Swift River- Pediatrics. Scenario #3 LOC - normal I suggest 10 units of regular. Psychological Needs - increased Deficient knowledge Pain - normal -Ask the patient`s husband if he has a copy of the updated advance directive Impaired skin integrity: False Wash hands In his confusion, he becomes combative and pulls out his IV. Use therapeutic communication/active listening on continuous pulse ox -Administer pain medication and call provider for a fentanyl or hydromorphone hydrochloride prescription. Inform & educate spouse Psychological Needs: Normal acuity Scenario #3 Talk w/ her stating surgery is over and she did great Observe & mark Scenario 5 Temperature is now 102.8 Monitor for adverse effects Wash/glove hands change diet to HH 6.) Document teaching moment, Educational Needs: Increased acuity Explain to Mrs. Whitmore Bleeding, risk for Proved PRN you take his vital signs which are T 101.3, P 88, R 24, BP 116/84 Inspect cast site Repeat 1mg of Atropine administration w/in 3-5 minutes of first dose Ineffective peripheral tissue perfusion: False Scenario #3 Body image disturbance: False Visual assess During the follow up nursing assessment, Ms. Hatcher complains about the NG-tube causing her pain in her nasal area. Assess respiratory status by observation Scenario #2 Wash & glove Contact HCP Document Fall Risk: Normal acuity Fall, risk for Notify lead RN/Dr Scenario #2 Full assessment Interviewing pt. Provide initial report and assist RRT Scenario #2 Fall Risk: Increased acuity Scenario 1 Inspect cast site Audiology changes, risk for 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 . Remove potential harmful objects Pt Kenny Barrett is nauseated and complains of dizziness when he sits up. lay on their side, Acute pain Impaired comfort: True Assess for fall risk Observe for bleeding Document Don new gloves Monitor and evaluate Scenario 3 Use therapeutic Hold next dose Encourage Mr. Dominec to discuss w/ his partner his best tx options. Scenario 2 Use therapeutic Neurological: Increased acuity Have an aide sit w/ Ms. Barkley while you obtain the IV supplies and notify the HCP of her declining condition. Documents all interactions Have secretary Your coworkers are asking you questions about mr. Dominec. Rank as most concerning for labs Take initial VS was admitted Scenario 4 Escort pt. Offer nutrition Teach Cameron Consult Psychology for referral 6.) 4-Provide necessary equipment Knowledge deficit: True Scenario 5 Provide 20 gram carb Evaluation pt. Pain Level: Normal acuity -Assist patient in performing hand hygiene Document -Speak slowly in a normal tone of voice Ensure the bed -Rate patient's pain on a scale of 1-10To determine level of pain for intervention Inspect site Pain - increased Now, third day post-op, Mrs. Stukes appears sad and depressed upon entering the room Scenario #2 Impaired mobility Educate pt regarding condition Peripheral neurovascular dysfunction: False Scenario 5 Anxiety Repeat 1mg atropine Set her up w/ a video chat w/ her family Psychological Needs - normal, Scenario #1 Administer IV ABX Scenario #5 Check I&O Initiate IV heparin Provide emotional support Contact charge nurse Full assessment Scenario 1 It is now the second day post op and his is given discharge information. Contact HCP if pt status does not improve Explain that Docetaxel Sensorium - normal, Deficient fluid volume Reassess BP & P Assess documented pain Scenario #4 Have daughter stay, Educational - increased Scenario 2 Ms. Rails shares with you her fear of being discharged home to an abusive husband. Assist anesthesia Scenario 2 Pain - normal Safety- Evaluate/modify mobility plan, Physiological- Constipation: False Start O2 Identify the client Health Change - increased Pt has a hx of COPD, HTN, DM II, and a recent MI. Scenario 2 Ask pt. Restart IV Scenario 1 Reorient pt to person, place & time NG tube to LIS The nurse repositioned the pt to the left side to decrease pressure on the sacrum and rt heel. He has a history of a Myocardial Infarction, MI, one year ago, and has refused all cardiac rehab, and has not had another cardiac event. Anxiety: True Administer digoxin immune Fab 240mg (6 vials) Note time when Health Change - increased Assess MR. Martinez's willingness Bleeding, risk for: True Obtain translator Fall Risk: Normal acuity Self-actualization- Acute Pain: True Scenario #4 Scenario #2 Assess toe movement -Sit at the patient's eye level and ensure they can see your lip movement and facial expression Psychological Needs - increased, Acute pain Health Change: Increased acuity Fall Risk - normal Provide Mophine Sulfate 4 mg IV Educate pt. Scenario 3 Scenario 4 - Fear Post op day 3 time for dressing change stump. Encourage PO fluids NKDA. Begin fluid and electrolyte You enter patient's room. Scenario #2 Evaluate understanding Obtain doppler pulse Scenario #3 - Fall, risk for -Check the chart for the presence of a DNR order to provide the code team Document rhythm Notify lead RN/ DR of new circumstances Scenario #4 Reassure patient of options 2-Stop the infusion Deficient knowledge: False - Health Change - increased Dr. Brown gives orders to remove NG-tube set to gravity and to begin a clear liquid diet Remove infiltrated IV Scenario 4 Ensure documentation Wash and glove hands Encourage first IS Scenario 5 Explain to Roger Full assessment Lubricate tip of enema Sleep deprivation: False. Remind pt. Have pt put on a mask Scenario 2 Assess pt and family readiness to learn Notify lead RN/Dr Evaluate pt. Wash hands Notify the HCP using SBAR Pt. Prepare for external pace-maker placement -Gas exchange Gas exchange, risk for Impaired gas exchange: True Check for breathing and carotid pulse Psychological Needs - increased Following isolation precautions, you notice several family members are by his bedside and none of them are wearing face masks as requested by the sign on the door. Request possible change in medication and more frequent VS checks - Physical mobility, impaired Scenario #2 I am concerned about keto-acidosis and, I am calling about Joyce Workman. -Contact the appropriate department to see the status of the advance directive Verify call light Her temp is 100.8, BP 100/62, P 92, R 21, SpaO2 91. Report current urinary output quantify per hour and color of urine -Call RRT and prepare SBAR Review pain medication order mary_heath32. Report finding to HCP using SBAR. I am concerned about keto-acidosis and the complications of hyperglycemia. Deficient knowledge Reassure pt. Administer medication Assess for contraindications q 5 min Scenario #4 Scenario 5 View VCBC Glucose Regulation Swift River.docx from NURSING 246 at Colorado Christian University. Discuss lifestyle changes Ask surgeon Administer PRN constipation medications Initiate large bore IV Fear: True Charge the monitor Document rhythm Don Johnson Room 306. -Note that the family member support has been invaluable, and encourage her to stay. What should be included in the S? Check surgical consent for correct procedure and make sure operative site is marked. -Sit quietly with the patient allowing them enough time to respond Psychological Needs: Increased acuity, Physiological - - Health Change - increased Address concerns List the nursing care order. Place the syringe Scenario #4 Bleeding, risk for Pain Level: Increased acuity Scenario #3 Start studying swift river med surg. Pain - normal Use therapeutic communication to explain necessary procedure. -Obtain second witness for signing of discharge plan, Anxiety Scenario #3 - Deficient knowledge Ensure pressure dressing Report finding to HCP using SBAR. . Infection Scenario 5 Educate Ms. Horton that paroxetine (Paxil) is to be taken as ordered Establish responsiveness Orient pt. 5 Notify HCP of suspected abuse Assess Mrs. Workman's understanding Impaired skin integrity: True Notify lead nurse/Dr Inform healthcare provider exam 3. Psychological Needs: Increased acuity Scenario 1 Scenario #3 All 5 toes on the right foot are necrotic, absent pedal pulses, skin cold to touch, appearance dry, cracked and black up to mid-calf. Verify call light/ bed safety precautions Mr. Jones stated to the nurse that he "was scared to leave the room." Further questioning and clarification revealed Mr. Jones does not want to be alone and is afraid of being hurt . consult social service Schedule Cardiac rehab 1-Obtain a new IV site Full assessment He refuses to comply with dietary recommendations. Evaluate pt's understanding allow expression of feelings Health Change: Increased acuity Health Change: Increased acuity Administer ABX & start morphine Obtain translator Recommend pt. Explain that he will ETOH withdrawal, risk for, Scenario #1 Educate pt regarding RRT's purpose, Physiological Allow husband to make a quick one-minute visit Scenario 1 Health Change - increased Health Change: Increased acuity Initiate incident report, Acute pain Med-Surg SR. 83 terms. Encourage -Tell the patient that dressing must be changed, 1-Put a mask on yourself Nathaniel Gonzalez 15. Scenario #4 Educate pt regarding changes to POC Impaired mobility, risk for Pt states she has noted some "toe pain" but that it has been <3 on a scale of 1-10. Mr. Sturgess is recently dx w/ metastatic cancer of colon and he and his family have chosen only palliative care. Neurological - normal Place pt on PCA pump Establish responsiveness Remain with patient Provide comfort in pre-surgical room Mr. Dominec. ID pt. Disturbed sleep pattern: False