Clinical Worksheet
Date: 2/8/2021 Student Name:Jaleesa Taube Assigned vSim: Fundamentals – Edith Jacobson
Initials: Diagnosis: Admit Dx: HCP: Dr. Mark Isolation: standard IV Type: Critical Labs: Other Services:
E.J. Fracture - Hip Peterson Fall Risk: yes
Age: 85 Length of Stay: high fall Location:
M/F: F 1.5 days Consults: risk RUE
Code Status: Full Allergies: None Transfer: Fluid/Rate: Lactated Consults Needed: Social
code; CPR Full Ringers prior to surgery Worker – TCU post surgery
a
assist -order continuous 84 mL
vi
per hour.
d
Why is your patient in the hospital/ being treated today? (Answer in your own words and include the History of present Illness)?: My patient is being seen post a fall
e
at home. Complained of dizziness and fell. Fractured her left intertrochanteric hip. Scheduled for surgery tomorrow. Orders by provider for musculoskeletal assessment,
ar
education of safety and fall risk.
sh
Health History/Comorbities (that relate to this hospitalization): Pt. has a 10 year history of osteoporosis. Unsure of home safety, will need PT/OT at a TCU facility.
Evaluation of home.
as
w
m e
Path to Discharge: Safe a successful pain management prior to surgery. Surgery recovery. TCU admit and rehabilitation. Safety and education. Home evaluated for long
co rc
term care of self ability vs. need for a LTC or AL environment for more supervision.
o. ou
er res
Path to Death or Injury: Either unsessful surgery due to any unknown underlying comorbitiies. Embolism. DVT. Further falls.
eH y
rs udt
ss
hi
Date: 2/8/2021 Student Name:Jaleesa Taube Assigned vSim: Fundamentals – Edith Jacobson
Initials: Diagnosis: Admit Dx: HCP: Dr. Mark Isolation: standard IV Type: Critical Labs: Other Services:
E.J. Fracture - Hip Peterson Fall Risk: yes
Age: 85 Length of Stay: high fall Location:
M/F: F 1.5 days Consults: risk RUE
Code Status: Full Allergies: None Transfer: Fluid/Rate: Lactated Consults Needed: Social
code; CPR Full Ringers prior to surgery Worker – TCU post surgery
a
assist -order continuous 84 mL
vi
per hour.
d
Why is your patient in the hospital/ being treated today? (Answer in your own words and include the History of present Illness)?: My patient is being seen post a fall
e
at home. Complained of dizziness and fell. Fractured her left intertrochanteric hip. Scheduled for surgery tomorrow. Orders by provider for musculoskeletal assessment,
ar
education of safety and fall risk.
sh
Health History/Comorbities (that relate to this hospitalization): Pt. has a 10 year history of osteoporosis. Unsure of home safety, will need PT/OT at a TCU facility.
Evaluation of home.
as
w
m e
Path to Discharge: Safe a successful pain management prior to surgery. Surgery recovery. TCU admit and rehabilitation. Safety and education. Home evaluated for long
co rc
term care of self ability vs. need for a LTC or AL environment for more supervision.
o. ou
er res
Path to Death or Injury: Either unsessful surgery due to any unknown underlying comorbitiies. Embolism. DVT. Further falls.
eH y
rs udt
ss
hi
