Edith Jacobson vsim assignment PDF

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Vsim SBAR assignment for Edith Jacobson...

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vSim ISBAR ACTIVITY WORKSHEET INTRODUCTION

STUDENT Emily Choyce, Student RN, pre-operative surgical unit

Your name, position (RN), unit you are working on

SITUATION Patient’s name, age, specific reason for visit

BACKGROUND Patient’s primary diagnosis, date of admission, current orders for patient

ASSESSMENT

Edith Jacobson is an 85-year-old white female who was admitted last night after falling and fracturing her left hip and is schedule for surgery tomorrow.

Edith Jacobson has a 10-year history of osteoporosis, and her daughter reports that recently her mother has been having dizzy spells.

B/P: 126/76 HR: 85 and regular RR: 14 Temp: 99 F tympanic O2: 97 on room air. Pain: 2 – on movement of left hip. Pain medication is helpful to decrease pain. Heart Sounds regular without murmur, capillary refill less than 2 Lung Sounds Clear and bilaterally and equal Skin is normal elasticity, normal, not sweating with no signs of dehydration Bowel sounds normal Eye – pupil 5 mm, react to light bilaterally, extraocular movement within normal limits Neuro assessment – alert and oriented x4, patient is conscious, muscle strength and sensation are normal. Left lower extremity was not tested for muscle strength.

Mini Cog is normal GCS has changed to 15. Educated the patient on repositioning, activities, safety & fall risk, neuro checks, and plan of care.

Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs

RECOMMENDATION Any orders or recommendations you may have for this patient

Reposition every 2 hours, reinforce safety, and continue education on fall risk. Assess her pain level and medicate for pain if needed. Reassessed the GCS and neuro exam per providers order....