vSim_Clinical_Replacement_Packet
vSim ISBAR Activity Student Worksheet
Introduction RN: Odanayza Casanola Chavez
(Your name, position (RN), unit you are working Unit: Medical Unit
on)
Situation Patient’s name: Mona Hernandez
Patient’s name, age, specific reason for visit Age: 72-year-old
Reason for visit: Pneumonia in right lobe.
Background Primary diagnosis: Pneumonia.
Patient’s primary diagnosis, date of admission, Date of admission: 05/23/2020
current orders of patient
Current orders:
Admit to medical unit.
Vital signs every 4 hours.
Activity: up to chair, ambulate three times a day.
Diet regular as tolerated and encourage fluid
intake.
Labs: CBC with differential.
Arterial blood gas and BMP on admission.
Sputum specimen for Gram stain and culture.
Incentive spirometry and cough and deep
breathing exercises x10 every hour while awake.
Titrate oxygen to maintain SpO2 greater than
95% Flush saline locks every 8 hours and PRN.
Medications:
Acetaminophen 650 mg orally every 6 hours PRN
pain
Guaifenesin 100mg/5mL orally every 4 hours PRN
cough.
Hydrochlorothiazide 25 mg orally daily.
Moxifloxacin 400 mg IVPB daily.
Heparin 5000 units subcutaneously twice daily.
Call orders:
HR less than 60/min, greater than 120/min.
RR less than 10/min, greater than 30/min.
Systolic BP less than 90 mmHg, greater than 160
mmHg.
Diastolic BP less than 50 mmHg, greater than 95
mmHg.
Temperature less than 36.0 C (97 F), greater than
38.5 C (101.4 F).
, vSim_Clinical_Replacement_Packet
Assessment Vital Signs:
Current pertinent assessment data using head to Respiratory rate: 21 breaths per minute.
toe approach, pertinent diagnostics, vital signs Heart rate: 120 bpm
Pulse oximetry: 88 %
Blood Pressure: 146/88 mm Hg
Temperature: 101.0 F
Pain: 1
Head to toe assessment:
There are reduced breath sounds at the right lung
base.
The heart rate and rhythm are regular without
murmurs. The heart rate is fast.
Normal bowel sounds.
The chest is moving equally.
The radial pulse is strong and regular.
There is normal elasticity of the skin. Her skin is a
bit blue and warm and sweaty.
The capillary refill time is less than 2 seconds.
The IV sites have no redness, swelling, infiltration,
bleeding, or drainage. The dressing is dry and
intact.
The patient is conscious. The muscle strength and
sensation are normal.
Diagnostics:
Arterial Blood Gases:
pH: 7.3
HCO3-: 22 mEq/L
Base excess: -1
PCO2: 58 mmHg
PO2: 72 mmHg
SaO2: 94%
Blood Analysis:
Hb: 12.1 g/dL
HCT: 37%
Platelets: 351 *10^9/L
WBC: 18 *10^9/L
RBC: 4.2 *10^9/L
Electrolytes:
K+: 4.1 mEq/L
Na+: 140 mEq/L
Creatinine: 0.76 mg/dL
Cl-: 107 mEq/L
BUN: 10 mg/dL
Glucose: 102 mg/dL
X-ray of thorax shows right lower lobe
pneumonia.
vSim ISBAR Activity Student Worksheet
Introduction RN: Odanayza Casanola Chavez
(Your name, position (RN), unit you are working Unit: Medical Unit
on)
Situation Patient’s name: Mona Hernandez
Patient’s name, age, specific reason for visit Age: 72-year-old
Reason for visit: Pneumonia in right lobe.
Background Primary diagnosis: Pneumonia.
Patient’s primary diagnosis, date of admission, Date of admission: 05/23/2020
current orders of patient
Current orders:
Admit to medical unit.
Vital signs every 4 hours.
Activity: up to chair, ambulate three times a day.
Diet regular as tolerated and encourage fluid
intake.
Labs: CBC with differential.
Arterial blood gas and BMP on admission.
Sputum specimen for Gram stain and culture.
Incentive spirometry and cough and deep
breathing exercises x10 every hour while awake.
Titrate oxygen to maintain SpO2 greater than
95% Flush saline locks every 8 hours and PRN.
Medications:
Acetaminophen 650 mg orally every 6 hours PRN
pain
Guaifenesin 100mg/5mL orally every 4 hours PRN
cough.
Hydrochlorothiazide 25 mg orally daily.
Moxifloxacin 400 mg IVPB daily.
Heparin 5000 units subcutaneously twice daily.
Call orders:
HR less than 60/min, greater than 120/min.
RR less than 10/min, greater than 30/min.
Systolic BP less than 90 mmHg, greater than 160
mmHg.
Diastolic BP less than 50 mmHg, greater than 95
mmHg.
Temperature less than 36.0 C (97 F), greater than
38.5 C (101.4 F).
, vSim_Clinical_Replacement_Packet
Assessment Vital Signs:
Current pertinent assessment data using head to Respiratory rate: 21 breaths per minute.
toe approach, pertinent diagnostics, vital signs Heart rate: 120 bpm
Pulse oximetry: 88 %
Blood Pressure: 146/88 mm Hg
Temperature: 101.0 F
Pain: 1
Head to toe assessment:
There are reduced breath sounds at the right lung
base.
The heart rate and rhythm are regular without
murmurs. The heart rate is fast.
Normal bowel sounds.
The chest is moving equally.
The radial pulse is strong and regular.
There is normal elasticity of the skin. Her skin is a
bit blue and warm and sweaty.
The capillary refill time is less than 2 seconds.
The IV sites have no redness, swelling, infiltration,
bleeding, or drainage. The dressing is dry and
intact.
The patient is conscious. The muscle strength and
sensation are normal.
Diagnostics:
Arterial Blood Gases:
pH: 7.3
HCO3-: 22 mEq/L
Base excess: -1
PCO2: 58 mmHg
PO2: 72 mmHg
SaO2: 94%
Blood Analysis:
Hb: 12.1 g/dL
HCT: 37%
Platelets: 351 *10^9/L
WBC: 18 *10^9/L
RBC: 4.2 *10^9/L
Electrolytes:
K+: 4.1 mEq/L
Na+: 140 mEq/L
Creatinine: 0.76 mg/dL
Cl-: 107 mEq/L
BUN: 10 mg/dL
Glucose: 102 mg/dL
X-ray of thorax shows right lower lobe
pneumonia.
