Exam (elaborations) NURS 267 Med-Surg Lloyd Bennett Feedback Log & Sco

Exam (elaborations) NURS 267 Med-Surg Lloyd Bennett Feedback Log & Sco You arrived at the patient's side. 0:00 You introduced yourself. 0:10 Patient status - ECG: Sinus rhythm. Heart rate: 91. Pulse: Present. Blood pressure: 104/67 mm Hg. Respiration: 18. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C) 0:13 You washed your hands. To maintain patient safety, it is important to wash your hands as soon as you enter the room.  This study source was downloaded by from CourseH on :19:52 GMT -05:00 This study resource was shared via CourseH 4/22/2020 Feedback Log & Score — Lloyd Bennett Apr 21, 2020 7:22 PM 1:10 Patient status - ECG: Sinus rhythm. Heart rate: 91. Pulse: Present. Blood pressure: 105/68 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C) 1:26 You identified the patient. To maintain patient safety, it is important that you quickly identify the patient. 1:34 You asked if the patient was allergic to anything. He replied: 'No, I am not allergic to anything.' 1:43 You looked for normal breathing. He is breathing at 17 breaths per minute. The chest is moving normally on both sides. 2:10 Patient status - ECG: Sinus rhythm. Heart rate: 92. Pulse: Present. Blood pressure: 105/68 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C) 2:12 You attached the pulse oximeter. It is a good idea to monitor the saturation and pulse here. This will allow you to reassess the patient continuously. 2:24 You checked the radial pulse. The pulse is strong, 90 per minute and regular. It is correct to assess the patient's vital signs. 2:51 You measured the blood pressure at 104/68 mm Hg. It is appropriate to monitor the patient by measuring the blood pressure. 3:10 Patient status - ECG: Sinus rhythm. Heart rate: 92. Pulse: Present. Blood pressure: 105/68 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C) 3:17 You checked the temperature at the mouth. The temperature was 99 F (37 C). 3:43 You listened to the lungs of the patient. The breath sounds are normal. 4:04 You listened to the heart of the patient. There were only normal heart sounds. 4:10 Patient status - ECG: Sinus rhythm. Heart rate: 92. Pulse: Present. Blood pressure: 103/67 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 94%. Temp: 99 F (37 C) 4:18 You assessed the patient's dressing. This is correct. Assessing any dressings the patient has is always important. 4:27 You sat the patient up. 4:44 You obtained informed consent. This is correct. Obtaining informed consent before performing any procedure is important. 5:10 Patient status - ECG: Sinus rhythm. Heart rate: 93. Pulse: Present. Blood pressure: 104/67 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 94%. Temp: 99 F (37 C) 5:53 You verified the blood, patient ID, and type and cross-match by two nurses. This is very important to ensure patient safety. 6:10 Patient status - ECG: Sinus rhythm. Heart rate: 93. Pulse: Present. Blood pressure: 103/66 mm Hg. Respiration: 17. Conscious state: Appropriate. SpO2: 94%. Temp: 99 F (37 C) 6:15 You assessed the patient's IV. The site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact. This is correct. Assessing any IVs the patient has is always important.             This study source was downloaded by from CourseH on :19:52 GMT -05:00 This study resource was shared via CourseH 4/22/2020 Feedback Log & Score — Lloyd Bennett Apr 21, 2020 7:22 PM 6:29 You flushed the cannula. 6:39 You started infusing Packed red blood cells at 100 mL/hr. This is reasonable. It is important to use the basic rights of medication administration to ensure proper drug therapy.. 6:40 The patient started to develop a transfusion reaction. 6:54 You stopped infusing Packed red blood cells. Correct. It is very important to stop any transfusion and change the IV tubing down to the IV site when a transfusion reaction has developed. In clinical practice, the IV tubing and blood should be sent to the blood bank for analysis. 7:04 You looked for normal breathing. He is breathing at 19 breaths per minute. The chest is moving normally on both sides. 7:10 Patient status - ECG: Sinus rhythm. Heart rate: 96. Pulse: Present. Blood pressure: 111/72 mm Hg. Respiration: 19. Conscious state: Appropriate. SpO2: 94%. Temp: 99 F (37 C) 7:27 You checked the temperature at the mouth. The temperature was 99 F (37 C). 7:48 You measured the blood pressure at 112/72 mm Hg. 8:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 111/72 mm Hg. Respiration: 19. Conscious state: Appropriate. SpO2: 94%. Temp: 99 F (37 C) 8:14 You phoned the provider in order to discuss the patient. 9:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 109/70 mm Hg. Respiration: 18. Conscious state: Appropriate. SpO2: 94%. Temp: 99 F (37 C) 9:38 You obtained a urine dipstick and culture. 10:05 You took a venous blood sample. This is reasonable. 10:09 You started infusing normal saline at 100 mL/hr. 10:10 Patient status - ECG: Sinus rhythm. Heart rate: 94. Pulse: Present. Blood pressure: 110/70 mm Hg. Respiration: 18. Conscious state: Appropriate. SpO2: 94%. Temp: 99 F (37 C) 10:22 You contacted the blood bank. 11:10 Patient status - ECG: Sinus rhythm. Heart rate: 94. Pulse: Present. Blood pressure: 106/69 mm Hg. Respiration: 18. Conscious state: Appropriate. SpO2: 94%. Temp: 99 F (37 C) 11:27 You provided patient education. This is correct. It is important to use every opportunity to provide patient education. 12:10 Patient status - ECG: Sinus rhythm. Heart rate: 94. Pulse: Present. Blood pressure: 105/68 mm Hg. Respiration: 18. Conscious state: Appropriate. SpO2: 94%. Temp: 99 F (37 C) 12:23 A patient handoff was performed. Nursing management during the transfusion of blood or blood products is directed toward preventing transfusion complications, promptly recognizing            This study source was downloaded by from CourseH on :19:52 GMT -05:00 This study resource was shared via CourseH 4/22/2020 Feedback Log & Score — Lloyd Bennett Apr 21, 2020 7:22 PM complications if they develop, and promptly initiating measures to control any complications that occur. Acute hemolytic reaction, the most dangerous and potentially life-threatening type of reaction, occurs when the donor blood is incompatible with that of the recipient. Symptoms consist of fever, chills, low back pain, nausea, chest tightness, dyspnea, and anxiety. Then hypotension, bronchospasm, and vascular collapse may be the result. Febrile nonhemolytic reactions are the most common type of reaction, and allergic reactions are also possible. When complications occur, the nurse stops the transfusion immediately, assesses th