Swift River Medical Surgical
exam (47 questions & answers)
Ann Rails 38 years old, c/o back pain, non-significant past medical
history. No known allergies (NKA). Vital signs -BP 124/82, Temp
98.2, P 84, RR 22, SaO2 96%. Pain and numbness in legs for one
week. Abnormal left leg weakness, gait unsteady, 5/10 on
numeric pain scale. Neuro WNL, except leg pain upon movement.
Activity as tolerated with assistance. D/C plan- decrease pain and
restore normal gait. Regular diet. Dr. Suculo
Fall risk
Health change
Pain level
Educational Needs Psychological Needs
Arthur Thomason 56-year-old MVA victim, fourth day post op with
a splenectomy and femur repair. He is experiencing new onset of
shortness of breath and has a nasal cannula with 2L of Oxygen in
place. He is restless with slight confusion but is easily orientated
with attempts from nurse. Temperature spiked during the night to
102.4, BP now 146/94 which is slightly elevated, respirations at 30
bpm and slightly labored, heart rate 102 versus 84 from last night
shift. Skin cool to touch and appears pale. His coughing, to clear
his airway, appears ineffective. Recent chest X-ray shows diffuse
bilateral interstitial infiltrates in all lobes. Recent blood gases
demonstrate falling PaO2 (hypoxemia) and increasing CO2
(Hypercapnia). Mr. Thomason is anxious and is obviously
worsened from the shift before in overall condition.
Educational needs
Health change
LOC
Pain level
,Psychological needs
Safety
Calvin Umbyuma Mr. Umbyuma is a 42 y/o male who has been
admitted for complaints of shortness of breath with pleuritic chest
pain. He was diagnosed with HIV positive antibodies over a year
ago. He has recently been traveling back to his home country of
Kenya to visit his sick mother. He received traditional medical
treatment at his village. His temp is 100.9 F, 38.3 C, R 22, P92, BP
152/89 PaO2 91%. Inflammatory markers - Erythrocyte
Sedimentation Rate (ESR) and C-Reactive Protein (CRP) are
elevated at 78.9 mm/h and 67.2 mg/L. He has been placed in a
room at the end of the hall.
Educational needs
Health change
Pain level
Cameron Daniels just turned 18 y/o. She is being admitted from
the ER with a diagnosis of pelvic inflammatory disease (PID). She
has heavy vaginal discharge with an unpleasant odor. She is
complaining of abdominal pain and looks pale. She was seen by
OBGYN in the ER and a culture was sent to the lab for Chlamydia
and Neisseria Gonorrhea. She was a very difficult IV start and has
a 23g saline lock (SL) in her right hand. They have ordered a liter
bolus of LR, but it is running very slowly and the IV is positional.
VS BP 96/58, P 116, R 18, T 101.2 PaO2 98%.
Educational
Health change
Pain level
Fall risk
Higher numbered acuities are at most risk.
Cameron Daniels, acuity 3, room 304
Acute discomfort
Alteration in mobility
, Knowledge deficit
Potential falls
Potential for infection Nausea
Higher numbered acuities are at most risk.
Arthur Thomaston, acuity 3, room 302
Alteration in comfort
Alteration in gas exchange
Ineffectual airway clearance
Potential for shock
Prolonged confusion
Anxiety/fear
Potential for failure to thrive
Higher numbered acuities are at most risk.
Calvin Umbyuma, acuity 2, room 303
Acute discomfort
Nausea
Potential for alteration in mobility
Potential for bleeding
Knowledge deficit
Grief
Peripheral Neurovascular dysfunction
Higher numbered acuities are at most risk.
Ann Rails, acuity 1, room 301
Acute discomfort
Alteration in comfort
Alteration in mobility
Chronic discomfort
Nausea
Potential for bleeding
Potential for falls
Knowledge deficit
Potential for infection
exam (47 questions & answers)
Ann Rails 38 years old, c/o back pain, non-significant past medical
history. No known allergies (NKA). Vital signs -BP 124/82, Temp
98.2, P 84, RR 22, SaO2 96%. Pain and numbness in legs for one
week. Abnormal left leg weakness, gait unsteady, 5/10 on
numeric pain scale. Neuro WNL, except leg pain upon movement.
Activity as tolerated with assistance. D/C plan- decrease pain and
restore normal gait. Regular diet. Dr. Suculo
Fall risk
Health change
Pain level
Educational Needs Psychological Needs
Arthur Thomason 56-year-old MVA victim, fourth day post op with
a splenectomy and femur repair. He is experiencing new onset of
shortness of breath and has a nasal cannula with 2L of Oxygen in
place. He is restless with slight confusion but is easily orientated
with attempts from nurse. Temperature spiked during the night to
102.4, BP now 146/94 which is slightly elevated, respirations at 30
bpm and slightly labored, heart rate 102 versus 84 from last night
shift. Skin cool to touch and appears pale. His coughing, to clear
his airway, appears ineffective. Recent chest X-ray shows diffuse
bilateral interstitial infiltrates in all lobes. Recent blood gases
demonstrate falling PaO2 (hypoxemia) and increasing CO2
(Hypercapnia). Mr. Thomason is anxious and is obviously
worsened from the shift before in overall condition.
Educational needs
Health change
LOC
Pain level
,Psychological needs
Safety
Calvin Umbyuma Mr. Umbyuma is a 42 y/o male who has been
admitted for complaints of shortness of breath with pleuritic chest
pain. He was diagnosed with HIV positive antibodies over a year
ago. He has recently been traveling back to his home country of
Kenya to visit his sick mother. He received traditional medical
treatment at his village. His temp is 100.9 F, 38.3 C, R 22, P92, BP
152/89 PaO2 91%. Inflammatory markers - Erythrocyte
Sedimentation Rate (ESR) and C-Reactive Protein (CRP) are
elevated at 78.9 mm/h and 67.2 mg/L. He has been placed in a
room at the end of the hall.
Educational needs
Health change
Pain level
Cameron Daniels just turned 18 y/o. She is being admitted from
the ER with a diagnosis of pelvic inflammatory disease (PID). She
has heavy vaginal discharge with an unpleasant odor. She is
complaining of abdominal pain and looks pale. She was seen by
OBGYN in the ER and a culture was sent to the lab for Chlamydia
and Neisseria Gonorrhea. She was a very difficult IV start and has
a 23g saline lock (SL) in her right hand. They have ordered a liter
bolus of LR, but it is running very slowly and the IV is positional.
VS BP 96/58, P 116, R 18, T 101.2 PaO2 98%.
Educational
Health change
Pain level
Fall risk
Higher numbered acuities are at most risk.
Cameron Daniels, acuity 3, room 304
Acute discomfort
Alteration in mobility
, Knowledge deficit
Potential falls
Potential for infection Nausea
Higher numbered acuities are at most risk.
Arthur Thomaston, acuity 3, room 302
Alteration in comfort
Alteration in gas exchange
Ineffectual airway clearance
Potential for shock
Prolonged confusion
Anxiety/fear
Potential for failure to thrive
Higher numbered acuities are at most risk.
Calvin Umbyuma, acuity 2, room 303
Acute discomfort
Nausea
Potential for alteration in mobility
Potential for bleeding
Knowledge deficit
Grief
Peripheral Neurovascular dysfunction
Higher numbered acuities are at most risk.
Ann Rails, acuity 1, room 301
Acute discomfort
Alteration in comfort
Alteration in mobility
Chronic discomfort
Nausea
Potential for bleeding
Potential for falls
Knowledge deficit
Potential for infection
