Edith jacob Clinical Worksheet Activity PDF

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v-sim assignment...

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Kanooj Khan Class: NO109/110 V-Sim: Edith Jacobson Assignment: Clinical Worksheet (next page)

Clinical Date:5/14/2020 Initial: EJ Age:83 M/F: F Code Status: Full

Student Name: Kanooj Khan Diagnosis: Fracture (Hip) Length of Stay: 1.5 days Allergies:NKA

Assigned vSim: 5/14/20 HCP: Blount Memorial Hospital Consults: MP

Isolation: Standard Fall Risk: fall risk precaution Transfer: N/A

IV Type: right hand Fluid/Rate: 84 ml/hr

Critical Labs: N/A

Other Services: PT therapy Dietary Nutritionist Consults Needed: PT therapist

Why is your patient in the hospital (Answer in your own words and include the History of present Illness):

Mrs. Jacobson is an 85-year-old white female who was admitted last evening after falling and fracturing her hip. Mrs. Jacobson has a 10-year history of osteoporosis. Health History/Comorbities (that relate to this hospitalization):

Osteoporosis Shift Goals/ Patient Education Needs: 1. Risk for infection: Goal; The patient will show no evidence of infection by end of the shift. 2. Acute Pain: Goal; The patient will pain verbalize pain level less than 1 by end of shift. 3. Impaired comfort Risk: Goal; The patient will verbalize feelings of comfort upon discharge. 4. Risk for altered skin integrity: Goal; The patient will maintain intact skin by discharge. Path to Discharge:  Participate as part of a multidisciplinary team to coordinate discharge planning efforts. The team may include the bedside nurse, care manager, primary care practitioner, and infection prevention specialist.  Assess the patient's and family's understanding of diagnosis, treatment, prognosis, follow-up, and warning signs for which to seek medical attention.  Provide a list of prescribed drugs, including the dosage, prescribed time schedule, and adverse reactions to report to the practitioner.  Instruct the patient how to take care of wound at home.  Document the patient's understanding of the teaching provided and any need for follow-up teaching. Path to Death or Injury:  Evaluate how the patient's current illness will affect independence.  Identify the patient's and family's goals, preferences, comprehension, and concerns about discharge.  Provide patient with contact information in case of emergency.

Alerts: What are you on alert for with this patient?    

Management of Care: What needs to be done for this Patient Today?

Fall risk Pressure ulcer Hand hygiene Monitor vital sign and labs values

1. 2. 3. 4. 5. 6.

Vital signs are stable Pain level is 2/10 Give the pain meds Assess patient status Education on fall risk prevention Antiembolism stocking application

What Assessments will focus on for this patient? Priorities for Managing the Patient’s Care Today  

Assess wound care Assess the pain level

1. Donned necessary PPE. 2. Assess labs, vital signs, 3. Assess wounds care for infection.

List Complications may occur related to dx, procedure, comorbidities:  

Patient maybe at risk of infection related to injury. Patient maybe at risk for acute pain related to disruption of skin tissue and muscle integrity.

What nursing or medical interventions may prevent the above Alert or complications?       

Turn an immobile patient frequently. Treat the patient's pain, as needed and ordered, using nonpharmacologic, pharmacologic, or a combination of approaches. Give prescribed drugs, such as morphine sulfate, initially for pain, and expect to switch to oral analgesics as soon as possible. Monitor closely if the patient is at high risk for adverse outcomes related to opioid treatment if prescribed. Reassess and respond to the patient's pain by evaluating the response to treatment and progress toward pain management goals. Encourage incentive spirometry hourly while the patient is awake. Monitor laboratory values, as ordered.

What aspects of the patient care can be Delegated and who can do it?  

Patient proper high fat and high protein diet can be delegated to dietary nutrition. Patient daily ambulation can be delegated to physical therapist....