vSim S Lin Clinical Replacement Packet Latest Update 2025

INTRODUCTION Your name, position (RN), unit you are Milagros Ballesteros, LPN, Surgical Unit working on SITUATION Patient’s name, age, specific reason for visit Sara Lin is an 18-year-old female patient who had an emergency appendectomy. It is day 2 postoperative, and Sara is expected to be discharged late this afternoon. We have discontinued her IV antibiotics after her morning dose. She will be getting oral meds today. BACKGROUND Sara presented in the ED 2 days ago with a 2-day history of nausea, vomiting, and increasing pain. She was taken to surgery that day and had an open appendectomy for a ruptured appendix. She has been stable since arriving to the unit. Her parents have been here with her most of the time and are very helpful and supportive. Patient’s primary diagnosis, date of admission, current orders for patient ASSESSMENT Sara is alert and oriented, appropriate for age. She needs to be reminded to use her incentive spirometer. Abdomen is soft, tender to touch. Bowel sounds active. She has progressed to regular diet, and she's eating small amounts. No nausea reported since postoperative day 1. The abdominal dressing was changed by the surgery team early this a.m. The incision is closed with staples; the edges are well-approximate and only slightly reddened with minimal serosanguinous drainage. Her sequential compression devices were discontinued, and her Jackson-Pratt drain was pulled this morning. A small amount of bleeding was present; no further bleeding is noted. This morning, she had her first small soft brown stool since surgery. Patient vitals -heart rate: 98, Blood pressure: 134/80 mm Hg, Respirations: 21, SpO2: 97%, Temp: 99 F. Current pertinent assessment data using head-to-toe approach, pertinent diagnostics, vital signs. RECOMMENDATION Transition Sara to oral antibiotics and pain medication. Provide discharge patient education on incision care, pain medication and antibiotics, signs of postoperative infection, activity restrictions, and surgical follow-up. Educate and return demonstration for the incentive spirometer Any orders or recommendations you may have for this patient Last Updated 12/19/2022 1 | P a g e Dat 9/16/21 Student Milagros Ballesteros Assigned Sara Lin e: Name: vSim: Initial SL s: Diagnosis: HCP: Isolation: IV Type: Critical Labs: Other Services Age 18 : Appendectomy Standard Peripheral IV WBC 15 (High) N/A M/F F : Length of Stay: Fall Risk: Location: Code Status: Full Code Consults: N/A Low Right Handd Consults Needed: N/A Allergies: NKA Transfer: Fluid/Rate: 5% Dextrose with 0.9% NaCl 125mL/hr Why is your patient in the hospital (Answer in your own words and include the History of present illness)? Sarah Lin, a healthy 18-year-old female, presented to ED three days ago with nausea, vomiting, and abdominal pain. Open appendectomy for ruptured appendix. Health History/Comorbidities (that relate to this hospitalization): Patient healthy, no other medical history. Shift Goals/ Patient Education Needs: 1. Assess pain and medicate as needed 2. Monitor vital signs 3. Assess surgical site for abnormal findings 4. Educate and use incentive spirometer Path to Discharge: Maintain vitals within normal findings and monitor surgical site for worsening findings.