Fundamental- Vsim Kim Johnson clinical worksheet

KIM JOHNSON- CLINICAL WORKSHEET KJ 26F DX- T8 SCI LOS- 1 day NKA No falls No critical labs PT needed to see Rehab facility. Status post GSW T8 comorbidity Shift goals and Pt ducations- straight cath and info on that, focus on repositioning in bed Path to DC- successfully cath independently (show back) and needs assistance with ADLs Path to Death/Injury- Sepsis (not cathing properly) and pressure ulcers (skin hygiene and repositioning to prevent pressure ulcers) BACK- Alert- urinary retentions, resp compromise, constipation, dvt, proper nutrition, pressureulcer Focus- respiratory, skin, GI/GU, PO intake (leads to skin breakdown and PU) Complications rt to DX- Pressure ulcers, bowel obstructions, resp complications, infections, risk for PE (lack of movement) Interventions- straight cath (prevent uti and retn) turn, pulmonary toiley, TCDB, bowel regimen (rectal stimulation) compression stockings- Management of Care- Per Orders VS Q8- reg hi fiber, Q8 I&O, straight cath Q4 (bladder scan) meds reviewed and administered Priorities- Straight Cath with Education, OOB with TCDB Delegations- Turning This study source was downloaded by from CourseH on :04:58 GMT -05:00 Distribution of this document is illegal Want to earn $103 per month?