VSim Health Assessment Case 1: Josephine Morrow
Documentation Assignments
1. Document Ms Morrow’s skin assessment using the Braden scale.
Patient sensory acuity: slightly restricted (3)- Awake and responsive to verbal orders, Ms
Morrow had usual touch and pain feeling in her legs. She may not feel hurt because she has weak
flow due to venous insufficiency.
Patient moisture: rarely moist (4)
Patient activity: occasionally walks (3)
Mobility: minimal (2)- Pt is awake and aware but has limited mobility. Pt can move slightly but
not significantly on her own.
Nutrition: insufficient (2)
Friction and shear: a potential problem (2)
Overall Score: 16 (mild risk)
2. Document the teaching on promoting circulation to Ms Morrow
The client was given information on how to recover venous return. While lying or sitting, the
client was told to alter positions and walk about, raise their legs, and exercise their legs. The
patient was also taught how to wear compression leggings.
3. Document your assessment of Ms Morrow’s skin for the charge nurse using the SBAR
format.
Situation – The pt, 80, has a venous stasis ulcer on her lower right leg. Preventing skin
breakdown, promoting wound healing, and improving venous return are all goals of the
treatment approach. Ms Morrow has been under my care for the last 12 hours.
amurimi
Documentation Assignments
1. Document Ms Morrow’s skin assessment using the Braden scale.
Patient sensory acuity: slightly restricted (3)- Awake and responsive to verbal orders, Ms
Morrow had usual touch and pain feeling in her legs. She may not feel hurt because she has weak
flow due to venous insufficiency.
Patient moisture: rarely moist (4)
Patient activity: occasionally walks (3)
Mobility: minimal (2)- Pt is awake and aware but has limited mobility. Pt can move slightly but
not significantly on her own.
Nutrition: insufficient (2)
Friction and shear: a potential problem (2)
Overall Score: 16 (mild risk)
2. Document the teaching on promoting circulation to Ms Morrow
The client was given information on how to recover venous return. While lying or sitting, the
client was told to alter positions and walk about, raise their legs, and exercise their legs. The
patient was also taught how to wear compression leggings.
3. Document your assessment of Ms Morrow’s skin for the charge nurse using the SBAR
format.
Situation – The pt, 80, has a venous stasis ulcer on her lower right leg. Preventing skin
breakdown, promoting wound healing, and improving venous return are all goals of the
treatment approach. Ms Morrow has been under my care for the last 12 hours.
amurimi
