Fundamental- Vsim Jared Griffin Clinical Worksheet|GRADED A+2022

Clinical Worksheet Date: 3-4-2021 Student Name: Carly Gee Assigned vSim: Jared Griffin Initials: JG Age: 63 Diagnosis: R TKA HCP: N/A Isolation: contact precautions IV Type: none Location: Right hand Critical Labs: CL – (101-111 meq/L) 100 Other Services: N/A M/F: M Code Status: full code Length of Stay: 2 days Allergies: Codeine Consults: Respiratory therapist Fall Risk: Yes Transfer: no Fluid/Rate: N/A Glucose (fasting) 110 Consults Needed: physical therapy Why is your patient in the hospital (Answer in your own words and include the History of present Illness): Patient had a R total knee arthroplasty and is currently a postoperative patient Health History/Comorbities (that relate to this hospitalization): History of osteoarthritis, and hypertension Shift Goals/ Patient Education Needs: 1. assess the pain level 2. have Mr. Griffin do the incentive spirometer 10 each hour 3. educational wound care and PPE 4. bend knee at 90 degrees Path to Discharge: bend knee at 90 degrees. Get pain level to a 0 at all times. Strengthen respiratory rate. Make sure patients wife is aware of all educational protocol for patient. Alerts: What are you on alert for with this patient? (Signs & Symptoms) 1. infection 2. pain 3. hypertension What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?) 1. vital signs 2. assess patient’s wound 3. assess pain level List Complications may occur related to dx, procedure, comorbidities: 1. Pain related to TKA surgery yesterday morning. Clinical Worksheet (Continue to next page) Management of Care: What needs to be done for this Patient Today? 1. Pain assessment and rounding every 2 hours, or as needed. 2. Physical Therapy at 1000 3. Vital signs to be taken and recorded as needed. 4. Medications given on time and as needed for pain. 5. Making sure the incentive spirometer is being used as ordered and the patient is up moving around, as well as drinking fluids. 6. Making sure the wound/dressing is being assessed as needed. Priorities for Managing the Patient’s Care Today 1. Putting fall precautions in place. 2. Making sure the wound/dressing is clean, dry, and intact. 3. Making sure the patient is using the incentive spirometer as ordered. 4. Making sure patient is up moving around and not in bed all day. What aspects of the patient care can be Delegated and who can do it? Unlicensed Assistant Personnel can do the following: assess vitals, assist with ambulation to and from the bathroom, offer the patient fluids, assist with repositioning the patient, making sure the bed is in the lowest position and call light is in reach. Distribution of this document is illegal Want to earn $103 per month?