Assessment Case 09 Edith Jacobson DA Final PDF

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Download Assessment Case 09 Edith Jacobson DA Final PDF

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vSim Health Assessment Case 9: Edith Jacobson Documentation Assignments 1. Document your findings related to the focused assessment regarding Mrs. Jacobson’s neurologic status. Include her responses to your assessment. When I checked her pupils, they were round and reactive to light. During her mini-cog assessment, she did great. She was able to repeat the words I told her to remember and drew the correct time on the clock. While checking her GCS assessment, she got a 15, which is normal.

2. Document your findings related to the Mini-Cog and falls assessments of Mrs. Jacobson. Include her responses to your assessments. She was aware of her risks for falling. She showed me that she understood by telling me that she will use the call light when trying to go to the bathroom or to get out of the bed at all. She was able to recall the 3 words I asked her to remember and was able to draw the accurate time on the clock

3. Referring to your feedback log, document all nursing care provided and Mrs. Jacobson’s response to this care. I assessed her pain level (which was a 2 in her left leg that worsens with movement); I educated her on fall risks and asking for help to get up, pain management and plan of care; She had previous knowledge on each of the things I educated her on. I performed a focused neuro assessment (mini-cog & GCS), and she was able to recall the words I asked her to remember and drew the correct time on the clock. She got a 15 on her GCS, which is normal.

4. Document all patient teaching regarding assessments and safety issues provided to Mrs. Jacobson, and her response to the teaching. I educated her on use of her call bell for assistance to get out of bed for any reason, and she showed previous knowledge on that. I told her I had to perform some assessments on her, which initially she seemed anxious about, but after I explained what I was doing, it seemed to ease her anxiety

5. Document your handoff report in the SBAR format to communicate Mrs. Jacobson’s future needs.  S: This is Edith Jackson, 85-year-old female who was admitted after having a dizzy spell, resulting in a fall where she fractured her hip and hit her head. An x-ray has been taken and shows a left hip fracture. She also had a CT of her head, and those results showed that there was no intracranial bleeding. There was a concern regarding her orientation during the previous night, when she had a score of 14 on the Glasgow Coma Scale. From vSim for Nursing | Health Assessment. © Wolters Kluwer.

 B: She has a 10 year history of osteoporosis and history of dizzy spells  A: Her vital signs remained stable throughout the shift, as well as her pain. She has morphine prescribed q 4 hrs for pain. I educated her on fall risks and safety, which she had previous knowledge on. I did a mini-cog and GCS on her also and she was normal on both.  R: I would recommend continuing the neuro assessments on her as well as keeping her pain under control.

From vSim for Nursing | Health Assessment. © Wolters Kluwer....