V Sim christopher isbar PDF

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vSim ISBAR ACTIVITY INTRODUCTION

STUDENT WORKSHEET Salicity M. Mason (LPN) - medical surgical

Your name, posi�on (RN), unit you are working on

SITUATION Pa�ent’s name, age, specific reason for visit

BACKGROUND Pa�ent’s primary diagnosis, date of admission, current orders for pa�ent

ASSESSMENT Current per�nent assessment data using head to toe approach, per�nent diagnos�cs, vital signs

RECOMMENDATION Any orders or recommenda�ons you may have for this pa�ent

Christopher Parrish 18-year-old male Cystic Fibrosis No known allergies Primary Dx - Cystic fibrosisAdmitted on 01/03/2021Orders - Vital signs every 4 hours, daily input and output, daily weight, chest X-ray, NG tube insertionDiet - High calorie, high protein, high fat, regular diet, supplement with high protein snacks. Fluid nutrition 1.5 kcal 720 kcal over 8 hours during the night. Snack consisting of 2 multivitamin tablets provided PO every morning.Medications - Pancrelipase enzymes 5 capsules PO before meals and tube feedings, 3 capsules PO with snacks

Chest - All findings normal/normal heart sounds/clear lung soundsAbdomen - All findings normal/normal bowel soundsArms - All findings normalLegs - All findings normalSkin - All findings normal, normal turgor, hydrationMucosa - Moist, no signs of dehydrationVitals Temp 99 F, Pulse - 84 regular, RR - 12, SPO2 97% on room air, BP 122/72, Pain - 0/10 Head - All findings normal/neuro assessment normal/pupils dilated 4mm Id recommend continuous assessment of dietary intakeConsult with nutrition Assisting with enteral tube feedings and assessment of NG tube...