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Nurse's Notes	Vital Signs
0800: 62-year-old client brought to emergency department by spouse after tripping at home 6 hours ago. Right midfoot swollen with large amount of bruising on toes and sides of foot. Less swelling on ankle. No external bleeding or wounds. Reports pain 10/10 and unable to stand on foot, unable to move without difficulty, increased pain with palpation of superior aspect of foot. Able to move toes and dorsiflex foot, pedal pulse palpable, capillary refill delayed. Has history of hypertension, L meniscus repair 6 years ago, hepatitis A as a child. 0900: X-ray of the foot indicates a nondisplaced fracture of second and third metatarsals. Able to move toes. Capillary refill 2 seconds. Pain rated at 8/10. 1000: Health care provider applied fiberglass cast at 0930. Able to move toes. Demonstrated crutch walking without weight-bearing on R foot across floor and up and down stairs. Spouse instructed on how to assist with ambulation and how to get client in and out of the car. The nurse has reviewed the 0800 and 0900 nurse's notes and is planning care.

For each potential nursing intervention, specify if the intervention is indicated or contraindicated for this client.

Assessment Intervention	improved	No Significant Change	Declined
BP 134/90		O
Pain 5/10	O
O2 saturation 94%
RR 12			O
capillary refill time O

1.“목 뒤에 ball 있는 것 같아요”, 쉰 목소리, 휘징

어떤 질환인거 같아

PUD

GERD

Gasteric ulcer

peritonitis

2. NGN 휘징, 쉰목소리, 누울때, 밤에 상복부 통증, “목 뒤에 ball 있는것 같아요”, 담배 35년, chest pain 7/10 남성 -> 진단될수 있는것 고르기

GERD,

후두암,

MI

oral cancer

asthma

lung cancer

vocal cord disease

peptic uncer

4. insomnia

자기전 tv보도록 하겠다

napping은 아침과 점심에 10분 이내로 limit하겠다

잠들기 힘들면 침대에서 내려오지마라

환자 30분 안에 잠 못들면 침대 나가라#

5.차지 간호사가 한 간호사가 신규한테 “너 뭐하는거야? 학교에서 대체 뭘배웠니?” 라고 하는걸 들었다 이건 뭐냐

libel

slander

horizontal violence

assertive 어쩌구

In nursing, "violence" between a charge nurse and a new nurse can refer to two primary types of negative interactions: vertical violence and bullying. Vertical violence involves abusive behaviors between individuals at different hierarchical levels in the nursing profession, such as a charge nurse (a more experienced nurse in a leadership role) towards a new nurse. Bullying, in this context, is repeated, unwanted harmful actions intended to humiliate or distress the recipient, and can involve both overt and covert behaviors.

In a workplace context, "violence" between a charge nurse and a new nurse, especially when involving false statements, could be a case of defamation. If the charge nurse makes false, damaging statements about the new nurse to others, and those statements harm the new nurse's reputation or ability to do their job, it could be considered slander (if spoken) or libel (if written).

6.정신과 병동에서 간호사 두명이 엘리베이터를 탔다ㅡ순간 "우리 병원 입원한 그환자 가족들 너무 안좋다...등등 욕하는거.."  slander에 해당되는 것?

환자가 모르기 때문에 문제될것이 없다.

엘리베이터에 전부 의료인이니 문제가 안된다

환자가족을 모욕하는 slander에 포함된다.

환자를 없는자리에서 욕하는건 완전한 처벌이 가능한 범죄이다

7. 저칼륨혈증 유발하는 것

크론병

addison disease

cushing disease

liver cirrhosis

8.UAP Assign intervention

new cast 한 환자 circumference marking

reinforce한다 드레싱 어쩌구 throghbleeding ?

notify the nurse 환자 pain

iv rate 조절

9. Sickle cell disease 환아 급성통증 관련 엄마 발언. Sata

I may use opioids narcotics

I can use pain control only as needed

warm compress for alleviating pain is good

I’ll increase fluid intake

10. SCA 있는환자 말중 맞는말? 멀티

오피오이드 약 먹겠다.

필요하면 진통제 먹겠다.

따뜻한 샤워? 몸을 따뜻하게한다.

추운지방 여행을 계획중이다.

정기적인 치과치료 예약할수있다.

11. SCA crisis SATA

cold compression 해줌

mild illness 일지라도 병원감

물을 제한함

activity 중에 자주 쉬도록 해줌

all 접종 해준다

warm pad apply

•see the hematologist every 6 to 12 months

•see an eye doctor every year

•need pulmonary function tests (PFT) once as a teenager and once as a young adult (if you have asthma, you might need PFTs more often)

•get screening labs and urine studies every year

•possibly need imaging studies done like X-rays, MRIs, or ultrasounds

12. Therapeutic 토론? 에 참여할 수 있는 환자

조현병

양극성장애

nonverbal 주요우울증

panic attack

Therapeutic group therapy is available for patients with conditions including depression, anxiety, post-traumatic stress disorder (PTSD), substance use disorders (SUDs), eating disorders, and chronic pain. It can also benefit elderly individuals struggling with loneliness and may be adapted for patients with schizophrenia or personality disorders. However, some conditions, such as acute psychotic symptoms, active suicidal thoughts, or severe cognitive impairment, may make a patient unsuitable for group therapy

13.levodopa 맞는 것?

① OTC에서 비타민 사먹겠다.

② 약먹는동안 protein 섭취 제한한다

③ 약먹는동안 eye examination 하겠다. 1년에 한번씩

14.산모 분만이후 자궁저부 말랑, 한쪽으로 치우쳐 있음, 패드 젖었있다. 자궁 마사지했고 misoprostol  (cytotec) 주입, 소변제거  Hb 떨어짐

6번째 애기낳은 여자 PPH&boggy&deviation

자궁수축제 주고 도뇨관

피나는 이유&감염생기는 이유 유추

documentation

early ambulation

15.NGN .GIbleeding.coffee ground emesis->병원에서 bright red 토혈

환자가 bed 옆에 토혈함. lap 은 pt연장, hb, hct 낮게 나옴 (지문 짧음)

peptic ulcer Ds.환자 hematemesis한다

환자가 bed 옆에 토혈함. lap 은 pt연장, hb, hct 낮게 나옴

coffee ground emesis, PUD의심, OTC aspirin 먹고있음 중재

ngn 피 토하는 환자 뭐 준비해야될까

수술준비,

라인준비

수혈준비

EGD

16.Ngn셋트 .주제 hemorrhage . Coffe ground 토하고 밝은색 피토함

.50대 Er로 옴 ~hb  8 wbc 500 k 5.4

처치 indicated not indicated

수혈 –not indicated

K 검사f/u-indicated

bed rest –indicated

lactate solution - indicated

crowed area avoid-indicated