Nursing 206 Clinical Worksheet Sara Lin

Date: Student Name: Assigned vSim: Sara Lin Initials: S.L. Age: 18 y.o. M/F: Female Code Status: Full Diagnosis: Post-op appendectomy d/t appendicitis Length of Stay: Allergies: NKA HCP: Consults: Isolation: None Fall Risk: High Transfer: IV Type: Peripheral Location: Right hand Fluid/Rate: Critical Labs: WBC: 15 Other Services: Consults Needed: Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: Sara Lin is in the hospital due to a ruptured appendix. She was experiencing nausea, vomiting, and increasing pain when she arrived to the emergency department. She then was taken back to surgery for an appendectomy and is now recovering. Health History/Comorbidities (that relate to this hospitalization): Sara has no past medical problems. For this hospitalization, she presented to the ED with nausea, vomiting, and increasing pain. Shift Goals/ Patient Education Needs: 1. Assess patients surgical dressing and look for signs and symptoms of infection (vital signs, redness, edema, pus) 2. Manage patients pain level, give medications as needed. 3. Educate patient on how to care for their surgical incision and also signs and symptoms of an infection (redness, increased pain at site, edema, pus) 4. Educate patient on their activity level when discharged (up as tolerated, no heavy lifting, and no driving) Path to Discharge: Patient and designated care giver are educated on how to care for the surgical wound (ok to shower, place clean and dry dressing on after), when and how to take prescribed medications (educate the importance of finishing antibiotics), and activity level (no heavy lifting, ok to be up as tolerated, and no driving). Path to Death or Injury: If the patient does not follow their activity restrictions (no heavy lifting) or take their prescribed antibiotics, the surgical site could become infected which could create an injury and lead to death.