V Sim Clinical Worksheet - Harry Hadley PDF

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Summary

V Sim...

Description

vSim Clinical Worksheet

Initials: HH

Date

Diagnosis: Cellulitis

Age: 78 Year old M/F: M

Student Page 2

Assigned Sim: Harry Hadley

HCP:

Isolation: N/A

IV Type:

Consults:

Fall Risk:

Location:

Length of Stay: Admitted on 04 /11/2020

Critical Labs: Results

Other Services:

Consults

Transfer: Fluid/Rate:

Dietician

Code Status: Full code Allergies:

Why is your patient in the hospital (Answer in your own words and include the History of present Illness): Mr.Harry Hadley is a 78-year-old Caucasian male , came to the ED with his wife 1 hour ago on referral from his provider. He has a wound infection on his lower right leg, which tested positive for MRSA bacteria. He has moderate pain and is very frustrated that the infection is not healing. He had a feral cat back sometimes back and his provider called him this morning with the lab results showing positive for MRSA bacteria. The wound was also not getting better, and he was experiencing more pain, redness, and swelling of his leg Health History/Comorbities (that relate to this hospitalization): Mr. Hadley has been taking oral amoxicillin for 3 days, as prescribed by his provider, to treat a case of cellulitis caused by a feral cat bite. His provider called him this morning with the lab results showing positive for MRSA bacteria. The wound was also not getting better, and he was experiencing more pain, redness, and swelling of his leg

Shift Goals/ Patient Education Needs:  Monitoring of vital signs 

Pain assessment



Pain management



Medication Administration

vSim Clinical Worksheet

Date

Student Page 2

Assigned Sim: Harry Hadley

 Path to Discharge: Patient is treated and evaluated of any underlying conditions Patient if free of DVT Patient wound is healed Patient is out of contact precautions Path to Death or Injury:  Gangrene on wound may lead to amputation of leg 

DVT

Alerts: What are you on alert for with this patient? (Signs & Symptoms) 1. Complications like DVT 2. Sepsis 3. Complication of getting suer infection

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

Sepsis

Management of Care: What needs to be done for this Patient Today? Monitor and manage Pain Monitor Vital signs Wound Care Adequate fluid intake to promote hydration Elevation of lower extremities Well balanced diet to promote wound healing Administer medication as ordered Obtaining lab specimens for testing What aspects of the patient care can be Delegated and who can do it? Medication administration- LPN CNA- peri care

vSim Clinical Worksheet



DVT



Superinfections

Date

Student Page 2

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

Elevation of extremity



Oxygen administration



Proper wound care



Prevention of injury and trauma to the affected leg



Proper Nutrition

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Assigned Sim: Harry Hadley...