V Sim Clinical Worksheet Fillable PDF

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Summary

Vsim...

Description

Date: Initials: Age: M/F: Code Status:

M.H. Male, 43 year old

Sigmoid Student Name: colosto Diagnosis: HCP: N/a my for rectal cancer Length of Stay:

Consults:

Assigned vSim: Isolation:

IV Type: Location:

None

Critical Labs:

Cbc and BMP daily

Other Services:

Full liquid diet

Right forearm

Fall Risk:

Fluid/Rate:

Consults Needed:

125 ml/ hr of dextrose 5 %

N/a None

N/a Transfer: Allergies:

None

With assistance

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

Sigmoid colostomy for rectal cancer.

Health History/Comorbities (that relate to this hospitalization):

Rectal adenocarcinoma

Nutrition and wou

Shift Goals/ Patient Education Needs: 1. Monitor pt and patient student

2.

Educate on Nutrition

3. Education on ROM and exercise

4. Education on ostomy care

Path to Discharge:

Dwound to heal on sacral area, patient is able to produce bowels in ostomy, patient demonstrates ostomy care.

Path to Death or Injury:

Infection/sepsis, DVT, fall, leakage around the stoma, bleeding, injury to surrounding organs, hernia.

Alerts: What are you on alert for with this patient? (Signs & Symptoms) Management of Care: What needs to be done for this Patient Today? 1. 2.

1. 2. 3.

Watch for swelling or discoloration in stoma, edema and pain in

Legs, infection symptoms in incisions.

3. 4.

Education, ab. Assessment, ostomy and wound care

5. What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?)

6.

1.

Priorities for Managing the Patient’s Care Today 1.

2.

Abdominal assessment, wound care, assessment of legs, labs 3.

2. 3.

Patient will demonstrate how to care for ostomy and monitor for signs of infection.

Call doctor, assess abdomen, wound, and ostomy

4. List Complications may occur related to dx, procedure, comorbidities: 1. 2.

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

DVT, infection, bile duct injury, bleeding, leakage around the stom

3.

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

1. 2. 3. 4.

Monitor Labs, patient education, know signs of infection, monitor

Doctor Nutrition to teach client about things to eat after an ostomy Occupational therapy: can teach client how to manage ADLs while having an ostomy Wound Care: address incisions and teach patient how to care for ostomy once discharged...