V Sim+Clinical+Worksheet - J Hoffman PDF

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vSim Clinical Worksheet Initials: JH

Diagnosis: Asthma

Page 2 HCP: Consults:

Isolation: n/a

IV Type: Peripheral

Fall Risk: n/a

Location: Right hand

Transfer: n/a

Fluid/Rate:

Critical Labs::

Other Services:

Age: 33 Year old M/F: Female

Length of Stay: 11/11/2020

Consults Needed: Code Status:N/a Allergies: Hay Fever

Why is your patient in the hospital (Answer in your own words and include the History of present Illness): Jennifer Hoffman is a 33-year-old female brought to the Emergency Department by her neighbor. She appears to be in respiratory distress, struggling to breathe. She is unable to speak other than simple one-word statements.

Health History/Comorbities (that relate to this hospitalization): She has a history of asthma since childhood with multiple emergency visits within the last year.

Shift Goals/ Patient Education Needs: 1. Respiratory assessment 2. Monitoring of vital signs 3. Monitoring the severity of the symptoms 4. Administration of medication as ordered Path to Discharge: Patient is free of asthma attack and is not in respiratory distress Path to Death or Injury: Acute respiratory failure

vSim Clinical Worksheet

Alerts: What are you on alert for with this patient? (Signs & Symptoms) 1. Low Oxygen levels 2. Respiratory distress- Dyspnea 3. wheezing 4. bronco constriction 5. Airway edema 6.Cough What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?) 1. Monitoring of vital signs 2. Use of peak flow meter 3.Adminstration of medications ordered 4. Auscultation of lung sounds List Complications may occur related to dx, procedure, comorbidities: 1. Respiratory failure 2. Severe wheezing 3.Permanent lung damage What nursing or medical interventions may prevent the above Alert or complications? 1. Medication administration to open airways 2. Administration of oxygen 3. Respiratory assessment 4. Use of peak flow meter

Page 2

Management of Care: What needs to be done for this Patient Today? 1. Medication administration 2.Monitorng of symptoms 3. Oxygen therapy 4. Iv access 5. IV fluids if patient is dehydrated

Priorities for Managing the Patient’s Care Today 1. Monitoring of vital signs 2. Medication administration 3. Oxygen therapy 4. Continuous pulse oximetry

What aspects of the patient care can be Delegated and who can do it? LPN- Medication administration CNA- Vital signs...