vSim ISBAR Activity Student Worksheet
Introduction
(Your name, position (RN), unit you are working , RN at Clinic
on)
Situation Danielle Young Bear is a 32-year-old Native
Patient’s name, age, specific reason for visit American female, came to the clinic today with
complaints of a persistent cough and fatigue that
have lasted for 2 weeks. It started as a common
cold, but she was concerned that it was something
more serious since the cough and fatigue have not
resolved yet. The signs and symptoms are
consistent with the aftermath of a common cold, so
this is not a big concern. However, she is taking
several different prescription drugs and is also self-
medicating with OTC medication and using herbal
therapies; I’m concerned about potential drug
interactions.
Background
Patient’s primary diagnosis, date of admission, Primary Diagnosis: Chronic Low back pain
current orders of patient Date of Admission: 07/23/2020
Current Order:
Obtain Vital Signs
Focused on pain assessment of patient’s back
pain
Assess Neurological Status
Reconcile patient’s medication to include all OTC
medications, all traditional herbal medications,
and all prescription medication order to be taken
at home.
Assessment
Current pertinent assessment data using head to Ms. Young Bear is alert and oriented. The lung
toe approach, pertinent diagnostics, vital signs sounds are clear bilaterally and there is a bit of
redness in the throat. I also checked her back and
there are no signs of serious injury.
Recommendation Take vital signs and do a focused pain assessment
Any orders or recommendations you may have and assess neurological status. Go through all of her
for this patient medications, including prescription medications,
OTC medications, and herbal therapies, and
perform medication reconciliation. Notify health
care provider with any findings.
This study source was downloaded by 100000807621742 from CourseHero.com on 03-16-2022 08:37:07 GMT -05:00
https://www.coursehero.com/file/69019065/Danielle-Young-Clinical-Packetdocx/
, Patient Education Worksheet
Name of medication, classification
Medication: Hydrocodone
Classification: opioid agonists nonopioid analgesic combinations
Safe dose or dose range, safe route
PO (Adults): Analgesic (in combo products)– 2.5–10 mg every 3–6 hr as needed; if using combination
products, acetaminophen dosage should not exceed 4 g/day and should not exceed 5 tablets/day of
ibuprofen-containing products; Antitussive– 5 mg every 4–6 hr as needed; Extended-release (Zohydro
ER)– 10 mg every 12 hr; may ↑ as needed in increments of 10 mg every 12 hr every 3–7 days; Extended-
release (Hysingla)– 20 mg once daily; may ↑ as needed in increments of 10–20 mg/day every 3–5 days.
Renal Impairment
PO (Adults): CCr <45 mL/min– Extended-release (Hysingla): ↓ initial dose by 50%.
Hepatic Impairment
PO (Adults): Extended-release (Hysingla)– ↓ initial dose by 50%.
Purpose of this medication
• Decrease in severity of moderate pain.
• Suppression of the cough reflex.
Patient education while taking this medication
• Advise patient to take medication as directed and not to take more than the recommended amount. Severe and permanent liver
damage may result from prolonged use or high doses of acetaminophen. Renal damage may occur with prolonged use of acetaminophen or
ibuprofen. Doses of nonopioid agents should not exceed the maximum recommended daily dose. Do not stop taking without discussing with
health care professional; may cause withdrawal symptoms if discontinued abruptly after prolonged use. Discuss safe use, risks, and proper
storage and disposal of opioid analgesics with patients and caregivers with each Rx. The Patient Counseling Guide (PCG) is available at
www.fda.gov/OpioidAnalgesicREMSPCG.
• Instruct patient on how and when to ask for and take pain medication.
• Advise patient that hydrocodone is a drug with known abuse potential. Protect it from theft, and never give to anyone other than the
individual for whom it was prescribed. Store out of sight and reach of children, and in a location not accessible by others.
• May cause drowsiness or dizziness. Advise patient to call for assistance when ambulating or smoking. Caution patient to avoid driving
or other activities requiring alertness until response to the medication is known.
• Advise patient to notify health care professional if pain control is not adequate or if severe or persistent side effects occur.
• Advise patient to change positions slowly to minimize orthostatic hypotension.
This study source was downloaded by 100000807621742 from CourseHero.com on 03-16-2022 08:37:07 GMT -05:00
https://www.coursehero.com/file/69019065/Danielle-Young-Clinical-Packetdocx/
Introduction
(Your name, position (RN), unit you are working , RN at Clinic
on)
Situation Danielle Young Bear is a 32-year-old Native
Patient’s name, age, specific reason for visit American female, came to the clinic today with
complaints of a persistent cough and fatigue that
have lasted for 2 weeks. It started as a common
cold, but she was concerned that it was something
more serious since the cough and fatigue have not
resolved yet. The signs and symptoms are
consistent with the aftermath of a common cold, so
this is not a big concern. However, she is taking
several different prescription drugs and is also self-
medicating with OTC medication and using herbal
therapies; I’m concerned about potential drug
interactions.
Background
Patient’s primary diagnosis, date of admission, Primary Diagnosis: Chronic Low back pain
current orders of patient Date of Admission: 07/23/2020
Current Order:
Obtain Vital Signs
Focused on pain assessment of patient’s back
pain
Assess Neurological Status
Reconcile patient’s medication to include all OTC
medications, all traditional herbal medications,
and all prescription medication order to be taken
at home.
Assessment
Current pertinent assessment data using head to Ms. Young Bear is alert and oriented. The lung
toe approach, pertinent diagnostics, vital signs sounds are clear bilaterally and there is a bit of
redness in the throat. I also checked her back and
there are no signs of serious injury.
Recommendation Take vital signs and do a focused pain assessment
Any orders or recommendations you may have and assess neurological status. Go through all of her
for this patient medications, including prescription medications,
OTC medications, and herbal therapies, and
perform medication reconciliation. Notify health
care provider with any findings.
This study source was downloaded by 100000807621742 from CourseHero.com on 03-16-2022 08:37:07 GMT -05:00
https://www.coursehero.com/file/69019065/Danielle-Young-Clinical-Packetdocx/
, Patient Education Worksheet
Name of medication, classification
Medication: Hydrocodone
Classification: opioid agonists nonopioid analgesic combinations
Safe dose or dose range, safe route
PO (Adults): Analgesic (in combo products)– 2.5–10 mg every 3–6 hr as needed; if using combination
products, acetaminophen dosage should not exceed 4 g/day and should not exceed 5 tablets/day of
ibuprofen-containing products; Antitussive– 5 mg every 4–6 hr as needed; Extended-release (Zohydro
ER)– 10 mg every 12 hr; may ↑ as needed in increments of 10 mg every 12 hr every 3–7 days; Extended-
release (Hysingla)– 20 mg once daily; may ↑ as needed in increments of 10–20 mg/day every 3–5 days.
Renal Impairment
PO (Adults): CCr <45 mL/min– Extended-release (Hysingla): ↓ initial dose by 50%.
Hepatic Impairment
PO (Adults): Extended-release (Hysingla)– ↓ initial dose by 50%.
Purpose of this medication
• Decrease in severity of moderate pain.
• Suppression of the cough reflex.
Patient education while taking this medication
• Advise patient to take medication as directed and not to take more than the recommended amount. Severe and permanent liver
damage may result from prolonged use or high doses of acetaminophen. Renal damage may occur with prolonged use of acetaminophen or
ibuprofen. Doses of nonopioid agents should not exceed the maximum recommended daily dose. Do not stop taking without discussing with
health care professional; may cause withdrawal symptoms if discontinued abruptly after prolonged use. Discuss safe use, risks, and proper
storage and disposal of opioid analgesics with patients and caregivers with each Rx. The Patient Counseling Guide (PCG) is available at
www.fda.gov/OpioidAnalgesicREMSPCG.
• Instruct patient on how and when to ask for and take pain medication.
• Advise patient that hydrocodone is a drug with known abuse potential. Protect it from theft, and never give to anyone other than the
individual for whom it was prescribed. Store out of sight and reach of children, and in a location not accessible by others.
• May cause drowsiness or dizziness. Advise patient to call for assistance when ambulating or smoking. Caution patient to avoid driving
or other activities requiring alertness until response to the medication is known.
• Advise patient to notify health care professional if pain control is not adequate or if severe or persistent side effects occur.
• Advise patient to change positions slowly to minimize orthostatic hypotension.
This study source was downloaded by 100000807621742 from CourseHero.com on 03-16-2022 08:37:07 GMT -05:00
https://www.coursehero.com/file/69019065/Danielle-Young-Clinical-Packetdocx/
