Jared Griffin v Sim test PDF

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vsim Jared Griffin...

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CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)

Methicillin-resistant Staphylococcus aureus (MRSA) is an Infection with a mutated strain of Staphylococcus bacteria that has become resistant to methicillin and other antibiotics. Easily spread by direct person-to-person contact. Community-associated MRSA infection, most commonly seen in young, heathy people such as athletes, without recent health care exposure.

PATIENT INFORMATION ANTICIPATED PHYSICAL FINDING DIAGNOSTIC TEST

Cultures of blood, nasal secretions, skin, or soft tissue are positive for the bacteria. Complete blood count (CBC) with differential may reveal an elevated white blood cell count, indicating infection.

Jared Griffin is a 63- year old African American male who had a right total knee arthroplasty (TKA) yesterday morning. Patient has a history of MRSA, which diagnosed 3 years ago. His has a history of osteoarthritis and mild hypertension.

Signs and symptoms related to the primary site of infection such as joints, skins, respiratory. •

Skin: erythema, edema, painful, warm to touch, pus

•

Furuncle: abscess with purulent drainage

ANTICIPATED NURSING INTERVENTIONS

•

• • • •

Provide emotional support to the patient and family member. Allow the patient to verbalize feeling and concerns. Provide an open discussion and answer the patient’s family’s question honestly and clearly in terms that they will understand. Use meticulous hand hygiene. Use appropriate personal protective equipment Use standard and contact precaution Provide skin and wound care Obtain cultures of the wound, as ordered

vSim ISBAR ACTIVITY INTRODUCTION

STUDENT WORKSHEET My name is Yingyi Huang, student nurse from Nova Southeastern University. I work on Orthopedic unit 0800.

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

SITUATION

My patient Jared Griffin is a 63- year- old African American male who had a right total knee arthroplasty(TKA) yesterday morning.

Patient’s name, age, specific reason for visit

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

Mr. Griffin has a history of MRSA, which was diagnosed 3 years ago when he had surgery for a hammertoe. He also has a history of osteoarthritis and mild hypertension. Admitted on 04/02/2020. Patient had drug allergies to Codeine. Current orders are Hydrochlorothiazide 25 mg orally twice daily.

ASSESSMENT

Vital signs performed: B/P: 135/80 mm Hg, pulse is 80 per minute, breathing at 15 bpm, Temperature is 98 F, SPO2 is 97%

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

Pain level was 2 on scale of 0-10. Patient states “It hurts a bit when I bend the knee”. Nothing made the pain better. The right knee can bend about 75 degrees. There is a dressing cover the skin lesion on the lower leg. There is normal elasticity of the skin. His color is normal and his is not sweating. The patient used an incentive spirometer as ordered.

RECOMMENDATION Any orders or recommendations you may have for this patient

Continue with contact precautions and observe for signs and symptoms of infection. Provides emotional support to the patient and family and carries out prescribed treatments. Assess vital sign and Pre-medicate patient before wound dressing.

PHARM-4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Oxycodone hydrochloride-acetaminophen

CLASSIFICATION: Oxycodone hydrochloride-acetaminophen: opioid analgesics

PROTOTYPE: Oxycodone hydrochloride-acetaminophen: morphine SAFE DOSE OR DOSE RANGE, SAFE ROUTE Oxycodone hydrochloride-acetaminophen: 5-10 mg q 3 3-4 hr initially, as needed PURPOSE FOR TAKING THIS MEDICATION Oxycodone hydrochloride-acetaminophen:

PATIENT EDUCATION WHILE TAKING THIS MEDICATION

Clinical Worksheet Date: 04/02/2020 Initials: Age: M/F:

JG 63

Student Name: Yingyi Huang Diagnosis: Osteoarthritis

HCP: Dr. Lonny Washington

Fall Risk:

Length of Stay: 1.3 days

Male

Code Status: Full code Allergies: Codeine

Isolation: contact

Consults: Right total knee arthroplasty (TKA)

Transfer:

Assigned vSim: Jared Griffin IV Type:

Location:

Peripheral IV Right Hand

Critical Labs: Complete Blood Count without differentia • Basic Metabolic Panel • Prothrombin Time (PT)

Other Services:

•

Consults Needed:

Fluid/Rate: Clindamycin 600 mg IV 8 hours for 3 doses

Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: Mr. Griffin had a right total knee arthroplasty (TKA) yesterday morning. Patient had a history of MRSA, which was diagnosed 3 years ago when he had surgery for a hammertoe. He also has a history of osteoarthritis and mild hypertension. Health History/Comorbities (that relate to this hospitalization): MRSA and osteoarthritis

Shift Goals/ Patient Education Needs: 1. Proper wound care to prevent infection 2. Educated about use of incentive spirometer 3.Educated about use personal protective equipment 4. Observe for signs and symptoms of infection Path to Discharge: • Patient will able to over and protect any wounds or breaks in the skin and how to perform wound care. • Patient will able to use assistive device, such as a walker, crutches cane • Safe ambulation practices

Path to Death or Injury:

Alerts: What are you on alert for with this patient? (Signs & Symptoms) 1.

Management of Care: What needs to be done for this Patient Today? 1. Turn and reposition the patient regularly and frequently

Pressure Ulcer - redness, warmth, and firmer

2. Perform wound care

2. Pain - facial grimacing, moaning, and restlessness

3. Educate about use of incentive spirometer

3. Infection and complications such as deep vein thrombosis

4.Educate about personal protective equipment What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?)

5.Perform active and passive of range of motion

1.

Skin integrity- inspect the surgical sites of any redness, drainage, temperature and lesion

6.Assist medications was ordered by Health Care Provider

2.

Pain assessment- using PQRST, and observe patient ‘s facial expression

Priorities for Managing the Patient’s Care Today 1. Turn and reposition the patient regularly and frequently

3.

Physical examination with signs and symptoms of DVT and need to notify a health care provider

2. Perform wound care 3. Perform active and passive of range of motion 4. Assist medications was ordered by Health Care Provider

List Complications that may occur related to dx, procedure, comorbidities: 1.

Deep vein thrombosis

2.

Immobility at the right knee

3.

Wound and skin appearance

What aspects of the patient care can be Delegated and who can do it? Help clients with task such as bathing, dressing and eating. Assist with vital signs and repositioning the client can be done by PCA.

What nursing or medical interventions may prevent the above Alert or complications? 1.

Turn and reposition the patient regularly and frequently

2.

Increase the client’s activity after surgery. Institute safety measures to reduce the risk for injury, such as from falls. Assist with active ROM exercise to unaffected limbs.

3.

Perform daily wound care and wound specimen collection if ordered

Clinical Worksheet

Reflection Questions Paste your reflection questions in the box below

Clinical Judgement Components Scoring: Exemplary = 4 point Accomplished = 3 points Developing = 2 points Beginning = 1 point Score: vSim 1

Noticing: Focused Observation: Recognizing Deviations from Expected Patterns: Information Seeking:

EAD B EAD B EAD B

Total for category: Interpreting: Prioritizing Data: Making Sense of Data:

EAD B EAD B

Total for category: Responding: Calm, Confident Manner: EAD B Clear Communication: EAD B Well-Planned Intervention/Flexibility: EAD B Being Skillful EAD B Total for category: Reflecting: Evaluation/Self-Analysis: EAD B Commitment to Improvement: E A D B

Total for category:

Score: vSim 2

Score: vSim 2...