Inform pt why you are doing neurological checks q30 minutes and perform another baseline neurological check Inform the pt why he will no be receiving lunch Notify charge RN of deterioration of pt Scenario 4 Remain w/ pt and turn him on his left side. Inform the pt of the plan of care/stat CT, and administer Tylenol 1g. Put side rails up and call light in pts hand Notify Physican and document Scenario 3 Contact radiology for a stat CT scan of the head. Ask pt to remain in bed, and not get out of bed w/o assistance. Inform pt that you will discuss findings and pain medication w/ HCP. Wiggins why the pain medicine must be held. Scenario 1 Check for cognition A/O x4 Check pupils - equal and reactive Check nose and ears for drainage Check cranial nerves - smile, tongue, shoulder shrug Assess extremity strength Scenario 2 Explain to Mr. Prepare the pt for emergency neuro surgery. Pt needs emergency neuro surgery in order to stop the b led and relieve the pressure on the brain. Scenario 5 The HCP has heard from the radiologist that there is a sub Duran hematoma on the left side of the brain. Wiggins experiences a generalized tonic/clinic seizure. neuro check: A/O x2, left pupil is larger than his right and is +5 to react to light, their is no evidence of any drainage, cranial checks are all normal and pt is less cooperative for extremity strength assessment. You check his VS and they are: BP 185/75, P 58, R 28 and irregular, T 99.1, PaO2 98. NPO Scenario 4 You accompany transport of Mr. Contact radiology for a stat CT scan of the head. Scenario 3 After sharing findings w/ the provider, he orders the following: 1. Scenario 2 Your neurological assessment concludes the following: A/O x4 appears normal, left pupil is slightly larger than his right and is +3 to react to light, there is no evidence of any drainage, cranial checks are WNL, and extremity strength is slightly diminished. You tell the pt that you must do a assessment before you can give him any medication. He is complaining that his headache is worsening. John Wiggins Scenario 1 You respond to Mr. Notify the social worker of need for a new nursing home placement option. Jones if he would like for a chaplain or minister to be called. Jones to cough and take deep breaths hourly Document findings from repeat assessment Scenario 5 Talk w/ Mr. Scenario 4 Notify HCP for change in respiratory assessment Administer nebulizer to per HCP order Reassess respiratory status Encourage Mr. Jones to seek assistance before getting out of bed Obtain a sitter to stay w/ pt. Jones back to bed Provide personal hygiene Remind Mr. Jones that he will be safe during his hospital stay Administer prescribed anxiolytics medication prior to transfer to CT area Offer UAP to accompany Mr. Jones on why he does not want to leave the room. Scenario 1 Wash hands Reassure pt that he is in a safe environment Interviewing pt regarding need for hospitalization Complete physical assessment Notify charge nurse and social services Scenario 2 Use therapeutic communication Seek clarification from Mr. He requests no visitors at this time, but later asks for his family to be called to discuss a plan of care. He insists that he is not hungry and refuses assistance with his meal. He does not want to return to the nursing home, and does not wish to burden or live with his children. Jones is now more alert and states he does not see the point in living anymore and wishes he would just die quietly. Based on assessment, nebulizer tx administered per MD orders. Jones was noted to have bilateral wheezing, R 24, some use of accessory muscles w/ respiration's, dullness to percussion in the left lower lobe, an an unproductive cough. Jones is resting quietly in the bed, R 22, slightly labored, color pink. Jones falls on his way to the bathroom Scenario 4 Mr. Jones does not want to be alone and is afraid of being hurt Scenario 3 Later in the evening Mr. Jones stated to the nurse that he "was scared to leave the room." Further questioning and clarification revealed Mr. Jones is scheduled for a full body CT scan. Tim Jones Scenario 1 You begin your shift assessment w/ Mr.
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