(solved) VSim Health Assessment Case 9: Edith Jacobson
Documentation Assignments
(solved) VSim Health Assessment Case 9: Edith Jacobson Documentation Assignments
VSim Health Assessment Case 9: Edith Jacobson
Documentation Assignments
1. Document your findings related to the focused assessment regarding Mrs. Jacobson’s
neurologic status. Include her responses to your assessment.
• Patient is Alert and Oriented x3.
• Pupils are both 5 mm and pupillary response are equal round reacting to light.
• Patient’s Mini-Cog assessment showed no signs of cognitive impairment.
• Patient has Spontaneous opening of the eyes resulted an addition of four in GCS score.
• Patient obeys verbal commands and adding six to the GCS score.
• Patient converse oriented that adds five to the GCS score.
2. Document your findings related to the Mini-Cog and falls assessments of Mrs. Jacobson.
Include her responses to your assessments.
• Mini-Cog assessment resulted five out of five indicates there are no sign of symptoms of
cognitive impairment.
• Educated the patient about the risk of fall and make sure that patient needs to understand
that she needs to call for assistance, for instance going to the bathroom or using bedpan.
3. Referring to your feedback log, document all nursing care provided and Mrs. Jacobson’s
From vSim for Nursing | Health Assessment. © Wolters Kluwer.
T his study source was downloaded by 100000843952123 from CourseHero.com on 04 -12-2022 13:17:54 GMT -05:00
https://www.coursehero.com/file/64357635/Edith-Jacobson-Documentation-Assignmentdocx/
, response to this care.
• Washing, introducing myself, and identifying the client to maintain patient safety.
• Patient has no allergies.
• Patient’s pain is two and located on her left leg. It hurts when she had any movement and
pain killers really made the pain better.
• I.V site has no swelling, infiltration, redness, bleeding or drainage. The dressing is dry
and intact.
• Heart rate: 84. Blood pressure: 128/77 mm Hg. Respiration: 14. SpO2: 97%. Temp: 37°C.
• Pupil equal round reacted to light.
• The Mini-Cog score was 5 out of 5, which is normal.
• Motor function was observed. The patient obeyed verbal commands added 6 point in
GSC score
• Spontaneous opening of the eyes resulted an addition of four in gcs score
• Educated a patient teaching to the client about client safety, diagnosis, and plan of care.
• Comfort my patient and discuss about pressing the call bell if they need some assistance.
4. Document all patient teaching regarding assessments and safety issues provided to Mrs.
Jacobson, and her response to the teaching.
From vSim for Nursing | Health Assessment. © Wolters Kluwer.
T his study source was downloaded by 100000843952123 from CourseHero.com on 04 -12-2022 13:17:54 GMT -05:00
https://www.coursehero.com/file/64357635/Edith-Jacobson-Documentation-Assignmentdocx/
Documentation Assignments
(solved) VSim Health Assessment Case 9: Edith Jacobson Documentation Assignments
VSim Health Assessment Case 9: Edith Jacobson
Documentation Assignments
1. Document your findings related to the focused assessment regarding Mrs. Jacobson’s
neurologic status. Include her responses to your assessment.
• Patient is Alert and Oriented x3.
• Pupils are both 5 mm and pupillary response are equal round reacting to light.
• Patient’s Mini-Cog assessment showed no signs of cognitive impairment.
• Patient has Spontaneous opening of the eyes resulted an addition of four in GCS score.
• Patient obeys verbal commands and adding six to the GCS score.
• Patient converse oriented that adds five to the GCS score.
2. Document your findings related to the Mini-Cog and falls assessments of Mrs. Jacobson.
Include her responses to your assessments.
• Mini-Cog assessment resulted five out of five indicates there are no sign of symptoms of
cognitive impairment.
• Educated the patient about the risk of fall and make sure that patient needs to understand
that she needs to call for assistance, for instance going to the bathroom or using bedpan.
3. Referring to your feedback log, document all nursing care provided and Mrs. Jacobson’s
From vSim for Nursing | Health Assessment. © Wolters Kluwer.
T his study source was downloaded by 100000843952123 from CourseHero.com on 04 -12-2022 13:17:54 GMT -05:00
https://www.coursehero.com/file/64357635/Edith-Jacobson-Documentation-Assignmentdocx/
, response to this care.
• Washing, introducing myself, and identifying the client to maintain patient safety.
• Patient has no allergies.
• Patient’s pain is two and located on her left leg. It hurts when she had any movement and
pain killers really made the pain better.
• I.V site has no swelling, infiltration, redness, bleeding or drainage. The dressing is dry
and intact.
• Heart rate: 84. Blood pressure: 128/77 mm Hg. Respiration: 14. SpO2: 97%. Temp: 37°C.
• Pupil equal round reacted to light.
• The Mini-Cog score was 5 out of 5, which is normal.
• Motor function was observed. The patient obeyed verbal commands added 6 point in
GSC score
• Spontaneous opening of the eyes resulted an addition of four in gcs score
• Educated a patient teaching to the client about client safety, diagnosis, and plan of care.
• Comfort my patient and discuss about pressing the call bell if they need some assistance.
4. Document all patient teaching regarding assessments and safety issues provided to Mrs.
Jacobson, and her response to the teaching.
From vSim for Nursing | Health Assessment. © Wolters Kluwer.
T his study source was downloaded by 100000843952123 from CourseHero.com on 04 -12-2022 13:17:54 GMT -05:00
https://www.coursehero.com/file/64357635/Edith-Jacobson-Documentation-Assignmentdocx/
