Swift River Medical-Surgical Exam
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Updated 2024/25
Ann Rails - Educational - Increased
II II II II II II II II
Fall Risk - Increased
II II II II
Health Change - Increased II II II II
Pain - Increased II II II
Psychological Needs - Normal II II II II
Sensorium - Normal II II
Ann Rails - Acute pain
II II II II II II II
Impaired comfort II
Impaired mobility II
Disturbed sensory perception II II
Fall, risk for II II
Peripheral neurovascular dysfunction II II
Ann Rails - Scenario #1
II II II II II II II
Use therapeuticII II
Educate pt. II
Evaluate pt. learning II II
Place call light II II
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Scenario #2 II
Wash and glove hands II II II
Assess
Provide comfort measures II II
Notify doctor II
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Scenario #3 II
Listen to pt. concerns II II II
Reassure pt. of options II II II
Notify lead nurse/doctor II II
Contact Social Services II II
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Scenario #4 II
Wash and glove hands II II II
Visual assessment II
Do not disturb
II II
,Verify Call Light II II
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Scenario #5 II
Assess for bowel sounds II II II
Encourage fluids/fiber/ambulation II
Evaluate pt. understanding II II
Attain fluids/fiber diet
II II
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Arthur Thomason - Educational - increased
II II II II II II II II
Health change - increased II II II
LOC - increased
II II
Pain - increased
II II
Psychological needs - increased II II II
Safety - increased II II
Arthur Thomason - Impaired confort
II II II II II II II
Impaired gas exchange II II
Ineffective airway clearance II II
Shock, risk for II II
Anxiety/fear
Failure to thrive, risk for II II II II
Arthur Thomason - Scenario #1
II II II II II II II
Assess
Replace O2 II
Use therapeutic
II
Notify Dr. and charge nurse
II II II II
Scenario #2 II
Remind physician II
Explain to physician II II
Assist physician II
Obtain recent II
Reassure pt. II
Scenario #3 II
Tap pt.
II II
Elevate HOB II
Call rapid response
II II
Start secondaryII
Remain with pt. II II
Scenario #4 II
Provide verbal report II II
,Emergency intubation II
Assume role II
Obtain pt. record II II
Provide information II
Scenario #5 II
You explain that his condition
II II II II
You explain that he is receiving
II II II II II
You have them remain with you
II II II II II
You escort them with you
II II II II
You call his doctor
II II II
Calvin Umbyuma - Educational - increased
II II II II II II II II
Fall Risk - normal
II II II
Health Change - increased II II II
Pain - increased II II
Psychological needs - normal II II II
Neurological - normal II II
Calvin Umbyuma - Acute pain
II II II II II II II
Deficient knowledge II
Calvin Umbyuma - Scenario #1
II II II II II II II
Place on respiratory isolationII II II
Ask Mr. U II II
Obtain blood cultures II II
Start IV II
Collect sputum culture II II
Scenario#2
Wash hand, don PPE II II II
Explain to the visitor II II II
Respiratory assessment II
Explain to Mr. U II II II
Place signage on door II II II
Scenario #3 II
Ask pt. what he knows
II II II II
Ask pt. what his mother's
II II II II II
Educate pt. II
Evaluate effectiveness II
Report findings II
Scenario #4 II
Pt. teaching
II
Contact respiratory therapy II II
, Chest x-ray II
Western blot II
Bronchoscopy
Scenario #5 II
Elevate HOB II
Initiate O2 at 4L II II II
Reassess VS II
Reevaluate amount of blood lost II II II II
Contact HCP II
Cameron Daniels - Educational - increased
II II II II II II II II
Fall Risk - increased
II II II
Health Change - increased II II II
Pain - increasedII II
Psychological Needs - normal II II II
Neurological - normal II II
Cameron Daniels - Acute pain
II II II II II II II
Impaired mobility II
Deficient knowledge II
Fall, risk for II II
Infection, risk for II II
Cameron Daniels - Scenario #1
II II II II II II II
Give tylenol II
Start another IV II II
Initiate bolus II
Request additional pain med II II II
Reasses temp in 1 hour II II II II
Scenario #2 II
Sit at an eye level
II II II II
Teach Cameron II
Evaluate understanding II
Contact charge nurse II II
Document pt's statements II II
Scenario #3 II
Provide emotional support II II
Assure pt. II II
Explain to pt. II II
Stress importance II
Inform pt. II II
Scenario #4 II
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