Week #3 Report Sheet and Self Eval.docx

Student Name: Yihan Yu 1.) How do you feel about your performance throughout this simulation? What did you do well? What could you have done better? -I feel better than the last 2 cases. I did well on the Analyze section. I should done better on the EHR section, need to pay attention on little details and taking good notes. 2.) On a scale 1-5, 1 being not confident at all and 5 being completely confident, how confident did you feel in completing the i-Human simulation case? Explain. -3 or 4. I still having trouble to ask some key questions, maybe there are too many choices which makes me use all 120 selection but still missing important ones. 3.) What was the patient’s main problem or problems? What concept or concepts does this problem(s) fall under? -His main problem is shortness of breath. The concept for this one would be Oxygenation. 4.) Do you feel more confident in caring for a patient with this problem after completing this simulation? Why or why not? -Yes, I do feel more confident in caring for a patient with COPD now, because I feel more familiar of those symptoms and knows what to expect. Monitor their oxygen saturation levels is the priority intervention. 5.) What do you think you learned from this simulation? What are one or two take-way points from this simulation that you can you use in a real clinical setting in the future? I learned that COPD is not simply a “smoker’s cough” but an under diagnosed and life-threatening lung disease. Some drug can be given to treat COPD patient are Albuterol, Ipratropium, and Cefuroxime to treat respiratory tract infection. Physical Exam HEENT: •Head - no visible or palpable mass or lesions, no deformities •Eyes - PERRLA, conjunctiva pink no discharge, sclera white, wearing glasses •Ears- no deformities, edema, or discharge noted •Nose - no discharge or polyps, no edema or tenderness •Throat/Mouth – mild blush tinge to lips, tongue pink in color, no lesions, mucous membranes dry, no swelling or ulcerations Skin: warm and diaphoretic Cardiovascular: Regular rhythm, no murmur or rubs, Capillary refill less than 3s, pulses are 2+ in all extremities, no edema Respiratory: barrel chest, inspiratory and expiratory wheezes, on 2L O2 via nasal cannula, no cyanosis Gastrointestinal: normoactive bowel sounds X4, abdomen nontender and non-distended, last BM yesterday, no scars or striae Genitourinary: no masses or tenderness, no urethral discharge Musculoskeletal: 3/5 bilaterally, equal ROM to all extremities Neurological: A&O x 4 Fall: Morse fall score 30 – low risk IV: RFA IV saline lock patent, infusing D5NS 75ml/hr, no S/Sx infiltration or infection Belongings: cell phone, wallet SBAR Situation: Hi Dr. Tate, this is Yihan from the medical unit, the RN taking care of your patient 75 years old Mr. Bundy. He has increased shortness of breath at rest, fever, and productive cough. Background: He was admitted for an acute COPD and states he ran out of his inhalers a week ago. Assessment: There is diffuse inspiratory and expiratory wheezes through bilaterally lung. Cyanosis to lips, warm and diaphoretic skin. BP 128/82, Pulse 88, RR 26, Temp 100.1F, and 86% on 2L nasal cannula. Unable to lay flat, prefers HOB 30-45 degrees. 2/10 pain to chest when breathing. Recommendation: Can you come to see Mr. Bundy as soon as you can? Also, would you like to increase his oxygen flow rate and order a febrifuge for his fever?