She is dressed in a long, blue velvet gown with a tiara on her head. As you move closer to her, you smell cigarette smoke. She is about 52 and 120 lbs. When you speak to her, she replies with short answers and makes facial grimaces. You begin to gather more data and decide to measure her vital signs: oral temperature 101.2 degrees Fahrenheit. Blood pressure 116/72. Right radial pulse is 122 bpm and feels weak. Respiratory rate is 18 breaths/min. Oxygen saturation is 99% on Room Air. You ask questions to obtain the history. The client states that her pain is in the right lower quadrant of her abdomen rated at a 7/10. She says it is constant and stabbing and worse with movement. She tried taking Tylenol last night but she states it did not do a thing. She knew she had a problem when she had trouble putting on her costume at the theater rehearsal this morning. She used meditation for 10 minutes backstage to get through the rehearsal but it was difficult. She says, I am the lead actress and opening night is in 3 days. What is the Subjective Data? What is the Objective Data? Using OLDCARTS describe what you know about the client. O L D C A R T S When writing up a Health History, what are the following components? Source of Information: Chief Complaint: History of Present Illness: Review of Symptoms: GTPAL: Genogram: With the information provided above, please write one sentence about the patient for each section of The Nursing Process: Create your Care Plan! The Nursing Process: Assessment: Diagnosis: Plan: Implementation: Evaluation: Communication: Give a brief definition or example of the following Open-ended questions: Closed- ended questions: Language Barriers: Health Literacy: Interpersonal variables: Cultural Competency Food and Beverage Taboos: Medical Intervention Taboos: Assessment Read the following scenario and answer the following questions (Scenario Repeated from Above): 32-year-old female who arrives at an urgent care center stating, my stomach has been killing me since last night. She is sitting in a chair, using her arms to hold her stomach as she rocks back and forth. She is dressed in a long, blue velvet gown with a tiara on her head. As you move closer to her, you smell cigarette smoke. She is about 52 and 120 lbs. When you speak to her, she replies with short answers and makes facial grimaces. Identify at least 2 SMART Goals for your patient 1. 2. What is your priority intervention for this patient? The patient suddenly has a seizure, what is your new priority? New Nursing Diagnosis? New Intervention? Differentiate subjective data from objective data by placing an S or an O after each of the following (some of them can potentially be both): complaint of sore shoulder _____ unconscious____ blood in urine _____ family has just moved to a new area _____ dizziness _____ sore throat _____ earache ______ weight gain ______ nausea ______ vomiting______ For the following situations, state the type of data collection you would perform (i.e., complete database, focused or problem-centered database, follow-up database, emergency database.) a.OxyContin overdose: b.Ambulatory, well individual at an outpatient clinic with a rash: c.First visit to a health care provider: d.Recently placed on antihypertensive medication: Dont Forget about Lab! Hand Hygiene, Sterile Field, Sterile Gloves, PPE, Proper Body Mechanics 1)When are the two times you MUST wash your hands with soap and water? (i.e. hand sanitizer is not acceptable) 2)List the steps of Hand Hygiene using Soap and Water: (Try to do it from Memory!) 3)What are the three different types of Transmission Precautions? 4)Give an example of when you would use each of the Transmission Precautions? 5)When donning PPE what is the First Step? Why is this the first step? 6)If you become contaminated while taking off your PPE, what should you do? 7)Risk for Falls: What are some common patient issues a nurse should be aware of? 8)What are some interventions you can perform to decrease a risk for falls? 9)How does a nurse safely use a transfer belt? Which patients are they helpful for? Whats the correct procedure? 10) Nurses are at an increased risk for back injuries. What kind of things can a nurse do/use to decrease their own risk for injury? [Show less]
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