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NURS 201 Swift River Notes 2020

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NURS 201 Swift River Notes 2020 

Linda Yu

 1

1

Assess vital signs and urinary output.

Establish baseline to determine if there is a reaction to blood transfusion.

 3

2

Start a secondary IV line, 20 gauge cath with normal saline TKO (blood tubing).

Best practice is to have a primary line dedicated to blood.

 2

3

Have a second licensed nurse sign & verify the correct identification on the blood request and blood unit.

Standard for safe practice to limit transfusion error.

 4

4

Take vital signs and start administration of blood.

Best practice is to take vital signs immediately before starting transfusion.

 5

5

Assess patient and vital signs Q5 for first 15 minutes, and be prepared to stop blood immediately if patient experiences increased temp, hematuria, or anxiety.

Transfusion reactions can occur immediately when administering a blood transfusion.

                             

Marcella como

 

xplanation

 1

1

Use therapeutic communication/Active Listening

Using therapeutic communication to assess is first step to understanding patient's psychological condition.

 2

2

Full Assessment

Full assessment is first step of establishes baseline of patient's physiological condition.

 3

3

Provide emotional support

After proper assessment, provide proper planning and intervention.

 4

4

Documentation

Document patient baseline assessment information for progression of patient.

 

Your order

Correct order

Step

Explanation

 1

1

Use therapeutic communication/Active Listening

Therapeutic Communication Assessment is first step to understanding patient request/concerns.

 2

2

Educate patient

Feeling of being "dirty" is common for rape victims.

 4

3

Provide supplies and needed instructions.

Demonstrates care for the patient. Patient may have questions regarding supplies or new surroundings.

 3

4

Offer to Assist

After receiving supplies and instructions patient may see obstacles where help may be needed. Also, interaction could diminish feelings of abandonment, isolation, and untouchability.

 

Your order

Correct order

Step

Explanation

 1

1

Use therapeutic communication/Active Listening

Listening to verbal & nonverbal messages for patient intent.

 2

2

Ask open-ended questions

Allows more opportunity for discussion.

 3

3

Seek clarification

Narrows down open-ended questions.

 4

4

Summarize discussion

States main points & allows for further planning.

 

 2

1

Restate or paraphrase patient statements

Conveys listening & understanding of message.

 1

2

Acknowledge patient's decision

Gives acceptance to wishes of patient after restating/paraphrasing.

 3

3

Review plan of action

Marks beginning of next phase of POC.

 4

4

Notify social services

Notifying social services is next step of plan of action.

 5

5

Document process

Accurate documentation is to be performed after patient care is performed, NEVER BEFORE!

 1

1

Review Labs

Negative/positive test results will dictate Education.

 2

2

Educate Patient-STD's and pregnancy

Education is achievable after understanding patient concerns.

 3

3

Provide emotional support

Nurse is to act as patient advocate and support person.

 4

4

Discuss Support Groups

Secondary issue designed to help victims with self-care.

 

 

Jose Martinez Room 304

Jose Martinez, Jose Martinez, 43- year old male experiencing chest pain while watching a state rival football game earlier in the evening. Chest pain became progressively worse, so he called for an ambulance to bring him to the Emergency Department. Once the ambulance arrived, he reported his pain as 10/10. The 12-lead EKG showed ST elevation. Vital signs were HR 160, BP 145/102, Respirations 23, and Pulse Ox 89%. He was given nitroglycerin during transport to the hospital with little relief. He complained of feeling “light- headed”. He has been admitted to the unit, and the pain has subsided. He does have a 10-year history of hypertension. He was transferred here to the cardiac stepdown unit from the ER, because no beds were open in cardiac ICU. Ambulance report: Nitroglycerin SL x 3, 12-lead EKG, Blood drawn for cardiac enzymes, Peripheral IV started to left forearm.

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[Solved] NURS 201 Swift River Notes 2020

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NURS 201 Swift River Notes 2020  Linda Yu  1 1 Assess vital signs and urinary output. Establish baseline to determine if there is a reaction to blood transfusion.  3 2 Start a secondary IV line, 20 gauge cath with normal saline TKO (blood tubing). Best practice is to have a primary line dedicated to blood.  2 3 Have a second licensed nurse sign & verify the correct identification on the blood request and blood unit. Standard for safe practice to limit transfusion error.  4 4 Take vital signs and start administration of blood. Best practice is to take vital signs immediately before starting transfusion.  5 5 Assess patient and vital signs Q5 for first 15 minutes, and be prepared to stop blood immediately if patient experiences increased temp, hematuria, or anxiety. Transfusion reactions can occur immediately when administering a blood transfusion.                               Marcella como xplanation  1 1 Use therapeutic communication/Active Listening Using therapeutic communication to assess is first step to ...
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NURS 201 Swift River Notes 2020  Linda Yu  1 1 Assess vital signs and urinary output. Establish baseline to determine if there is a reaction to blood transfusion.  3 2 Start a secondary IV line, 20 ...

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