Clinical Worksheet
Date: _10/08/2020_________ Student Name: ___Jackie Griffis_________ Assigned vSim: _Rashid Ahmed
Initials: RA
Age: 50
M/F: M
Code Status: Diagnosis: hypokalemia and dehydration
Length of Stay: D4
Allergies: None HCP: Dr. Who
Consults: Isolation: None
Fall Risk: Low
Transfer: NoneIV Type: Location: right arm
Fluid/Rate: 125 mL/hrCritical Labs: PH, HCO3, K+, Na+, BUNOther Services: Consults Needed: Why is your patient in the hospital (Answer in your own words and include the History of present Illness): A dmitted after 2-3 days of abdominal cramping, nausea, vomiting, and severe diarrhea 12 hours after eating lunch at a restaurant. Food and drink intake minimal since symptoms started. Was dizzy and weak.
Pt has no more nausea and slight diarrhea. Will be discharged later today.
Health History/Comorbidities (that relate to this hospitalization): Pt is in otherwise good shape.
Shift Goals/ Patient Education Needs: 1. Education on dehydration, medications, intake and output, and risk for falls/safety.
2. Assist pt with ambulation and range of motion exercises
3. Push PO fluids as tolerated and keep checking nausea symptoms/pain
4. Vitals q4h, and monitor I & O.
Path to Discharge: Education of the PT, assist pt with ambulation, and keep call button within reach, assist with range of motion exercises, push po fluids as tolerated, keep assessing nausea and pain levels, keep pt on regular medication schedule, clear fluid diet and progress as tolerated to regular diet.
This study source was downloaded by 100000812546443 from CourseHero.com on 09-27-2022 16:20:16 GMT -05:00
https://www.coursehero.com/file/71128699/VSIM-Clinical-1082020-Rashid-Ahmeddocx/ Path to Death or Injury: falls/head injuries, embolism, pressure injuries, cardiac arrythmia, cardiovascular disease
Clinical Worksheet (Continue to next page)
Alerts: What are you on alert for with this patient? (Signs & Symptoms) 1.Embolism 2. Falls/safety
3. Inadequate output
What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?) 1. Pt education/questioning
on bowel activity
2. Head to toe focused (abdomen) 3. Monitor I and O
List Complications may occur related to dx, procedure, comorbidities: Management of Care: What needs to be done for this Patient Today? 1. Vitals/auscultation of lungs, heart, bowels, skin 2. Educate patient & back to reg diet
3. Range of motion exercises
4. Ambulation
5. Monitor I & O
6. Push fluids PO as tolerated
Priorities for Managing the Patient’s Care Today 1. Vitals/Temp/listen to heart, lungs, bowels, check skin turgor
2. Push fluids PO and resume reg diet as tolerated
3. PT Education on dehydration, I and O, fall risk, and medications
4. Range of motion exercises, assisting with ambulation as tolerated
What aspects of the patient care can be Delegated and who can do it? Nutritionist- education, CNA- range of motion and assisted ambulation.
This study source was downloaded by 100000812546443 from CourseHero.com on 09-27-2022 16:20:16 GMT -05:00
https://www.coursehero.com/file/71128699/VSIM-Clinical-1082020-Rashid-Ahmeddocx/
Date: _10/08/2020_________ Student Name: ___Jackie Griffis_________ Assigned vSim: _Rashid Ahmed
Initials: RA
Age: 50
M/F: M
Code Status: Diagnosis: hypokalemia and dehydration
Length of Stay: D4
Allergies: None HCP: Dr. Who
Consults: Isolation: None
Fall Risk: Low
Transfer: NoneIV Type: Location: right arm
Fluid/Rate: 125 mL/hrCritical Labs: PH, HCO3, K+, Na+, BUNOther Services: Consults Needed: Why is your patient in the hospital (Answer in your own words and include the History of present Illness): A dmitted after 2-3 days of abdominal cramping, nausea, vomiting, and severe diarrhea 12 hours after eating lunch at a restaurant. Food and drink intake minimal since symptoms started. Was dizzy and weak.
Pt has no more nausea and slight diarrhea. Will be discharged later today.
Health History/Comorbidities (that relate to this hospitalization): Pt is in otherwise good shape.
Shift Goals/ Patient Education Needs: 1. Education on dehydration, medications, intake and output, and risk for falls/safety.
2. Assist pt with ambulation and range of motion exercises
3. Push PO fluids as tolerated and keep checking nausea symptoms/pain
4. Vitals q4h, and monitor I & O.
Path to Discharge: Education of the PT, assist pt with ambulation, and keep call button within reach, assist with range of motion exercises, push po fluids as tolerated, keep assessing nausea and pain levels, keep pt on regular medication schedule, clear fluid diet and progress as tolerated to regular diet.
This study source was downloaded by 100000812546443 from CourseHero.com on 09-27-2022 16:20:16 GMT -05:00
https://www.coursehero.com/file/71128699/VSIM-Clinical-1082020-Rashid-Ahmeddocx/ Path to Death or Injury: falls/head injuries, embolism, pressure injuries, cardiac arrythmia, cardiovascular disease
Clinical Worksheet (Continue to next page)
Alerts: What are you on alert for with this patient? (Signs & Symptoms) 1.Embolism 2. Falls/safety
3. Inadequate output
What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?) 1. Pt education/questioning
on bowel activity
2. Head to toe focused (abdomen) 3. Monitor I and O
List Complications may occur related to dx, procedure, comorbidities: Management of Care: What needs to be done for this Patient Today? 1. Vitals/auscultation of lungs, heart, bowels, skin 2. Educate patient & back to reg diet
3. Range of motion exercises
4. Ambulation
5. Monitor I & O
6. Push fluids PO as tolerated
Priorities for Managing the Patient’s Care Today 1. Vitals/Temp/listen to heart, lungs, bowels, check skin turgor
2. Push fluids PO and resume reg diet as tolerated
3. PT Education on dehydration, I and O, fall risk, and medications
4. Range of motion exercises, assisting with ambulation as tolerated
What aspects of the patient care can be Delegated and who can do it? Nutritionist- education, CNA- range of motion and assisted ambulation.
This study source was downloaded by 100000812546443 from CourseHero.com on 09-27-2022 16:20:16 GMT -05:00
https://www.coursehero.com/file/71128699/VSIM-Clinical-1082020-Rashid-Ahmeddocx/
