vSim Health Assessment Case 10: Rashid Ahmed

vSim Health Assessment Case 10: Rashid Ahmed Documentation Assignments 1. Document your findings and Mr. Ahmed’s reactions related to the focused assessment, including fluid balance, potassium replacement, and antibiotic therapy. 2. Document how patient education needs were addressed regarding the need for fluid replacement therapy. 3. Referring to your feedback log, document all nursing care provided and Mr. Ahmed’s response to this care. Date of Completion Jul 12, 2019 7:49 PM Rashid Ahmed Age: 50 years Diagnosis: Gastroenteritis; resolving Score 3 3 0 76% Feedback Log 0:00 You arrived at the patient's side. 0:00 You reviewed the patient information. 0:00 You reviewed the patient log. 0:00 You reviewed the diagnostics. 0:00 You reviewed the clinical observations. 0:00 You reviewed the MAR. 0:00 You reviewed the orders. 0:00 You reviewed the intake and output. 0:08 You washed your hands. To maintain patient safety, it is important to wash your hands as soon as you enter the room. 0:10 Patient status - ECG: Sinus rhythm. Heart rate: 76. Pulse: Present. Blood pressure: 112/73 mm Hg. Respiration: 16. Conscious state: Appropriate. SpO2: 98%. Temp: 98°F (36.7°C) 1:10 You put on gloves. 1:10 Patient status - ECG: Sinus rhythm. Heart rate: 76. Pulse: Present. Blood pressure: 112/72 mm Hg. Respiration: 16. Conscious state: Appropriate. SpO2: 98%. Temp: 98°F (36.7°C) 1:25 You introduced yourself. Always remember to tell the patient who you are. 1:41 You identified the patient. To maintain patient safety, it is important that you quickly identify the patient. 1:50 You asked the patient: Do you have any allergies? If so, what kind of reaction did you have? He replied: 'No, I am not allergic to anything.' 2:10 Patient status - ECG: Sinus rhythm. Heart rate: 76. Pulse: Present. Blood pressure: 111/73 mm Hg. Respiration: 16. Conscious state: Appropriate. SpO2: 98%. Temp: 98°F (36.7°C) 2:27 You educated the patient about the steps in the assessment. 2:51 You educated the patient about intake and output. 3:10 Patient status - ECG: Sinus rhythm. Heart rate: 76. Pulse: Present. Blood pressure: 113/73 mm Hg. Respiration: 16. Conscious state: Appropriate. SpO2: 98%. Temp: 98°F (36.7°C) 3:22 You asked the patient if he had any pain. He replied: 'Yes, I have some pain.' 3:32 You asked the patient if he could describe his pain. He replied: 'It's mild cramps in my stomach, but it is much better than it was.' 3:51 You asked: How would you rate your pain? He replied: 'Not too bad; it's about a 2. ' Consider doing this earlier. 4:03 You asked the patient: Where does it hurt? He replied: 'In the upper part, to the left in my stomach.' ………………………………..CONTINUED…………………………………