merged: Marvin Hayes Documentation, ISBAR, CONCEPT, GUIDED REFLECTION and CLINICAL WORKSHEET

Clinical Worksheet Date: __6/1/21___________ Student Name: _____Kelsie Clamp________________ Assigned vSim: ____Marvin Hayes________________ Initials: MH Age: 43 M/F: M Code Status: Full Code Diagnosis: Colorectal Cancer Length of Stay: 3 days Allergies: NKA HCP: Ryder Consults: No Isolation: Standard Fall Risk: No Transfer: No IV Type: Location: R Hand Fluid/Rate: N/A Critical Labs: CBC BMP Other Services: N/A Consults Needed: N/A Why is your patient in the hospital (Answer in your own words and include the History of present Illness): Mr. Hayes is a 43-year-old white male who underwent a laparoscopic abdominal perineal resection with a permanent sigmoid colostomy 3 days ago for rectal cancer. Health History/Comorbities (that relate to this hospitalization): Laparoscopic abdominoperineal resection; colorectal cancer Shift Goals/ Patient Education Needs: 1. A patient will learn how to keep the stoma clean, dry, and protected. 2. Have patient accustomed to looking at the colostomy. 3. During the first 6-8 weeks after surgery, the goal is to encourage the patient to avoid foods high in fiber as well as any other food that causes diarrhea or excessive flatus. 4. Patient will have positive statements concerning the ostomy and express interest in learning self care. Path to Discharge: Physical and psychological health is to be maintained; prevent post-operative complications; teach self-care when the patient returns home. Path to Death or Injury: Potential complication of colostomy surgery could lead to surgical wound infection. Potential complication of colostomy surgery could lead to thrombophlebitis. This study source was downloaded by from CourseH on :39:54 GMT -05:00 This study resource was shared via CourseH Alerts: What are you on alert for with this patient? (Signs & Symptoms) 1. Absence of bowel movements/sounds. 2. Pain on wound side, facial grimacing, moaning, and restlessness. 3. Infection including purulent drainage, increased drainage, pain, redness, and swelling in and around the wound, and increased body/wound temperature. What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?) 1. Focused GI assessment: Frequency, color, and consistency of bowel movements should be assessed. Listen at least 5 minutes for bowel sounds. If bowel sounds are absent, HCP needs to be contacted immediately. 2. Pain assessment: PQRST is very useful in assessing abdominal pain and other GI symptoms such as distention, nausea, and vomiting. 3. Wound assessment: Inspection (sight and smell) and palpitation for appearance, drainage, odor, and pain. Also determines the status of the wound; identifies barriers to the healing process. List Complications may occur related to dx, procedure, comorbidities: 1. Post-operative infection, stricture, abscess formation, pneumonia 2. Rectal bleeding 3. Bowel obstruction What nursing or medical interventions may prevent the above Alert or complications? Management of Care: What needs to be done for this Patient Today? 1. Perform basic assessment (temperature, pulse, BP, respirations, pain, etc). 2. Provide colostomy care including emptying an open-ended pouch, noticing leakage, and changing the skin barrier. 3. Educated the patient about diet. 4. Perform and educate the patient about the use of the incentive spirometer. 5. Educate the patient about ostomy care. 6. Assess the patient’s abdominal incision. Priorities for Managing the Patient’s Care Today 1. Assess the abdominal incision. 2. Educate patient about ostomy care. 3. Provide colostomy care including emptying an open-ended pouch, noticing leakage, and changing the skin barrier. What aspects of the patient care can be Delegated and who can do it? Meds can be passed by RN and LPN. CNA’s can maintain basic patient care and tasks. LPN or RN can collect labs and make care plans for patient. This study source was downloaded by from CourseH on :39:54 GMT -05:00 This study resource was shared via CourseH 1. Arrange for preoperative visit by wound, ostomy, and continence nurse. 2. Encourage coughing and diaphragmatic breathing exercises and incentive spirometry. 3. Assess the surgical site and perform site care as ordered; auscultate bowel sounds. 4. Note the integrity of the surrounding skin and check for passage of stool noting the amount, color, and consistency. This study source was downloaded by from CourseH on :39:54 GMT -05:00 This study resource was shared via CourseH Powered by TCPDF () CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS ANTICIPATED NURSING INTERVENTIONS Colorectal cancer is a malignant tumor of colon or rectum. It always involves adenocarcinomas and it has a slow progression. With the slow progression of the tumor it can remain asymptomatic for a long time. The tumors that are located in the sigmoid and descending colon undergo a circumferential growth and they constrict the intestinal lumen. Tumors in the ascending colon are usually large at diagnosis and are palpable on physical examination. This is the second most common cause of cancer death in the United States and the third most common type of cancer in men and women.  Enlarged inguinal and supraclavicular nodes  Abnormal bowel sounds  Abdominal mass (right-side tumors that usually feel bulky; tumors of transverse portion more easily detected)  Generalized abdominal tenderness  Iron deficiency anemia may be present.  Fecal occult blood test or fecal immunochemical test (FIT) may show blood in stools, a warning sign of colorectal cancer.  Carcinoembryonic antigen may be elevated; permit patient monitoring before and after treatment to detect metastasis or recurrence. Marvin Hayes is a 43- year-old white male who has rectal cancer. Three days ago, he underwent a laparoscopic abdominal perineal resection with a permanent sigmoid colostomy.  Assist with developing positive coping strategies. Arrange for the patient to speak with someone who has had a similar experience, if appropriate, to reduce fears and to mitigate feelings of being alone.  Give prescribed drugs. Provide information to the patient about prescribed chemotherapy, including possible adverse effects. Premedicate with antiemetics about 30 minutes before administration, as ordered.  Prepare the patient physically and psychologically for surgery.  Administer laxatives, enemas, and antibiotics preoperatively, as ordered.  Arrange for a preoperative visit by a wound, ostomy, and continence nurse if an ostomy is planned.  Anticipate needs and provide for rest periods. Cluster activities to allow for uninterrupted periods of rest; encourage the use of energy-conservation measures.  Apply antiembolism stockings or sequential compression stockings to prevent VTE.  Provide postoperative care. Assess cardiopulmonary status. Encourage coughing and diaphragmatic breathing exercises, and incentive spirometry. Advise the patient to splint the incisional area to decrease pain and facilitate coughing. Encourage early ambulation. This study source was downloaded by from CourseH on :37:06 GMT -05:00 This study resource was shared via CourseH vSim ISBAR ACTIVITY STUDENT WORKSHEET INTRODUCTION My name is Alexandra Avalos the registered nurse from the surgical unit with Marvin Haynes as my patient. Your name, positon (RN), unit you are working on SITUATION My patients name is Marvin Hayes a 43-year-old white male who has rectal cancer. Three days ago, he underwent a laparoscopic abdominal perineal resection with a permanent Patent’s name, age, specific reason for visit sigmoid colostomy. BACKGROUND Mr. Hayes has recently experiences weight loss, an increase in fatigue, narrowing stools with blood, which led to his diagnosis of rectal adenocarcinoma and his recent surgery. His current orders are vital signs every six hours, the use of the incentive spirometer at least ten times in an hour, complete blood count and basic metabolic panel daily and full liquid diet to be advanced as tolerated Patent’s primary diagnosis, date of admission, current orders for patent ASSESSMENT The patient’s vital signs have been stable with a saturation of 94%– 97%. Pain level is currently 1 after pain medication was administered an hour ago. The colostomy appliance is an open-ended pouch attached to a skin barrier. The stoma is red and moist with liquid, brown stool output. The three small abdominal incisions are open to air. There is a clean pad covering the perineal incision. Mr. Hayes has been up and ambulating and is taking full liquids. Current pertnent assessment data using head to toe approach, pertnent diagnostcs, vital signs RECOMMENDATION For Mr. Hayes the morning assessment the colostomy pouch must assessed and emptied if necessary. He can advance to a regular diet as tolerated. Start providing patient education to prepare him for discharge in 2–3 days. Any orders or recommendatons you may have for this patent This study source was downloaded by from CourseH on :37:06 GMT -05:00 This study resource was shared via CourseH PHARM-4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: 1. Enoxaparin sodium 2. Omeprazole 3. Hydrocodone bitartrate-acetaminophen CLASSIFICATION: 1. Therapeutic class: Anticoagulants Pharmacologic class: Low-molecular-weight heparins 2. Therapeutic class: Antiulcer Pharmacologic class: PPIs 3. Therapeutic class: Opioid analgesics Pharmacologic class: Opioid analgesics-para-aminophenol derivatives PROTOTYPE: 1. Levonox 2. Losec 3. Norco SAFE DOSE OR DOSE RANGE, SAFE ROUTE 1. Adults: 40 mg subcut daily with initial dose 2 hours before surgery. Give subsequent dose, as long as hemostasis has been established, 24 hours after initial preoperative dose, and continue once daily for 7 to 10 days. Treatment for up to 12 days has been well tolerated. Continue treatment during postoperative period until risk of DVT has diminished. 2. Adults: 40 mg PO every morning with clarithromycin 500 mg PO t.i.d. for 14 days. For patients with an ulcer at start of therapy, give another 14 days of omeprazole 20 mg PO once daily. 3. Adults and children age 14 and older: Adjust dosage according to severity of pain and patient response. Give 1 to 2 tablets (hydrocodone 2.5 to 5 mg/acetaminophen 300 to 325) P.O. every 4 to 6 hours. For oral solution, give 15 mL (hydrocodone 7.5 Mg/acetaminophen 325mg) or 11.25 mL (hydrocodone 10mg/acetaminophen 300 to 325mg) P.O. every 4 to 6 hours as needed PURPOSE FOR TAKING THIS MEDICATION 1. To prevent PE and DVT after abdominal surgery 2. Helicobacter pylori infection and duodenal ulcer disease, to eradicate H. pylori with clarithromycin (dual therapy) 3. Moderate to moderately severe pain PATIENT EDUCATION WHILE TAKING THIS MEDICATION 1. Instruct patient and family to watch for signs of bleeding or abnormal bruising and to notify prescriber immediately. Tell patient to avoid OTC drugs containing aspirin or other salicylates unless ordered by prescriber. Advise patient to consult prescriber before initiating herbal therapy; many herbs have anticoagulant, antiplatelet, or fibrinolytic properties. 2. Tell patient to swallow tablets whole and not to open, crush, or chew them. Give patient instructions on how to take oral suspension. Instruct patient to take drug at least 30 to 60 minutes before meals. Caution patient to avoid hazardous activities if dizziness occurs. 3. Caution patient or caregiver of patient taking an opioid with benzodiazepine, CNS depressant, or alcohol to seek immediate medical attention for dizziness, light-headedness, extreme sleepiness, slowed or difficult breathing. Instruct patient to avoid alcoholic beverages, prescription drugs, and OTC products that contain alcohol during treatment. This study source was downloaded by from CourseH on :37:06 GMT -05:00 This study resource was shared via CourseH Clinical Worksheet Date: April 15, 2020 Student Name: Alexandra Avalos Assigned vSim: Marvin Hayes Initials MH Age: 43 M/F: Male Code Status: Full Code Diagnosis: Colorectal Cancer Length of Stay: 3 days Allergies: NKA HCP: Allen Ryder Consults: Isolation: Standard Fall Risk: NA Transfer : NA IV Type: Peripheral Location: Right hand Fluid/Rate: Critical Labs: HCO3- Hb HCT Other Services: Consults Needed: Oncology Nutrition Respiratory Gastroenterologist Colostomy care Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: - Patient because he was experiencing weight loss, increasing fatigue and narrowing stools with blood which led to his diagnosis of rectal adenocarcinoma. Health History/Comorbities (that relate to this hospitalization): - No past history is related to his hospitalization, he was diagnosed with rectal cancer upon hospitalization Shift Goals/ Patient Education Needs: 1. Vital signs every four hours 2. Incentive spirometer at least ten times an hour 3. Stoma care 4. Risk factors and signs of recurrence Path to Discharge: - Assess the patient's level of independence prior to admission. - Evaluate how the current illness will impact the patient's independence. - Participate in a multidisciplinary team to coordinate discharge planning efforts. The team may include the bedside nurses, ostomy nurse, nutritionist, social worker, care manager, surgeon, and oncologist. - Determine the appropriate post-hospital setting to which the patient should be discharged. - Assess patient and family understanding of the diagnosis, treatment, prognosis, follow-up, and warning signs for which to seek medical attention. - Assess/confirm the patient's ability to obtain medications; identify the party responsible for obtaining medications. - Ensure that the patient and caregivers have been given the proper medical contact information. Path to Death or Injury: - Anemia - Postoperative infection, stricture, abscess formation, pneumonia - Adverse effects of chemotherapy and radiation This study source was downloaded by from CourseH on :37:06 GMT -05:00 This study resource was shared via CourseH Alerts: What are you on alert for with this patient? (Signs & Symptoms) 1. Vital signs 2. Bowel function 3. Postoperative complications What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?) 1. Vital signs every four hours 2. Auscultating bowel sounds 3. Assessing the colostomy pouch List Complications that may occur related to dx, procedure, comorbidities: 1. There could be post-operative infection 2. Depression 3. Pneumonia What nursing or medical interventions may prevent the above Alert or complications? 1. Use of the incentive spirometer at least ten times in an hour 2. Educating patient on how to properly take medication 3. Prepare the patient physically and psychologically for life change 4. Assess the surgical site and perform correct care Management of Care: What needs to be done for this Patient Today? 1. Vital signs every four hours 2. Assess the colostomy pouch, and empty if necessary 3. Educate patient on incentive spirometer 4. Have patient use incentive spirometer at least ten times in an hour 5. Educate patient on medication 6. Educate patient on proper care of stoma, and colostomy pouch Priorities for Managing the Patient’s Care Today 1. Have patient use incentive spirometer at least ten times in an hour 2. Vital signs every four hours 3. Assess the colostomy pouch, and empty it if necessary 4. Educate patient on incentive spirometer What aspects of the patient care can be Delegated and who can do it? - The CP can take the patients vital signs, assess and empty the colostomy pouch. The CP will also be able to teach patient how to use the incentive spirometer properly and have them use it at least ten times an hour Clinical Worksheet This study source was downloaded by from CourseH on :37:06 GMT -05:00 This study resource was shared via CourseH Reflection Questions Paste your reflection questions in the box below Opening Questions How did the simulated experience of Marvin Hayes’s case make you feel? - Treating Mr. Hayes’s case made me feel grateful that I do not have to have a colostomy pouch for the rest of my life. After this I will no longer take using the restroom normally for granted since there are many people like Mr. Hayes and it can happen to anyone at any time. Talk about what went well in the scenario. - I believe that the scenario overall went well, teaching Mr. Hayes how to use the incentive spirometer and having him use it ten times was what went more smoothly for me Reflecting on Marvin Hayes’s case, were there any actions you would do differently if you were to repeat this scenario? If so, how would your patient care change? - I would educate Mr. Hayes first on how to use the incentive spirometer before having him use it, when I first did the scenario, I didn’t do this and I felt like it could’ve gone better if I would have educated him before. Also, when I was cleaning the stoma for the first time, I didn’t change my gloves so that is something that I would definitely do differently. Scenario Analysis Questions* PCC What priority problem(s) did you identify for Marvin Hayes? - He has colorectal cancer he underwent a laparoscopic abdominal perineal resection with a permanent sigmoid colostomy PCC What potential problems could arise due to the newly placed colostomy? - There could be an infection. PCC Discuss what type of diet would be appropriate for Marvin Hayes. - A regular diet as tolerated PCC/T&C Discuss the importance of peer support groups with other adults with colostomies. - The importance of peer support groups with other adults with colostomies is that they get to meet other people that are just like them. The sadness that could be brought by a lifechanging event like this could be made a little bit better by having other people around that are going through the same thing. EBP Explain why it is important to measure the stoma at least once a week for the first 6-8 weeks after surgery. - It is important to measure the stoma at least once a week for the first 6 to 8 weeks after surgery because it ensures that you are wearing the correct pouching system size, it reduces discomfort. T&C What other interprofessional team members should be involved in Marvin Hayes’s care? - The team may include the bedside nurses, ostomy nurse, nutritionist, social worker, care manager, surgeon, and oncologist. I Cite one source that you could give to Marvin Hayes that would provide more information on colostomy care and resources. - This study source was downloaded by from CourseH on :37:06 GMT -05:00 This study resource was shared via CourseH This study source was downloaded by from CourseH on :37:06 GMT -05:00 This study resource was shared via CourseH This study source was downloaded by from CourseH on :37:06 GMT -05:00 This study resource was shared via CourseH Clinical Judgement Components Scoring: Exemplary = 4 point Accomplished = 3 points Developing = 2 points Beginning = 1 point Noticing: Focused Observation: E A D B Recognizing Deviations from Expected Patterns: E A D B Information Seeking: E A D B Total for category: Score: vSim 6 E EE 12 Score: vSim 7 Score: vSim 8 Interpreting: Prioritizing Data: E A D B Making Sense of Data: E A D B Total for category: EE 8 Responding: Calm, Confident Manner: E A D B Clear Communication: E A D B Well-Planned Intervention/Flexibility: E A D B Being Skillful E A D B Total for category: EE EE 16 Reflecting: Evaluation/Self-Analysis: E A D B Commitment to Improvement: E A D B Total for category: EE 8 This study source was downloaded by from CourseH on :37:06 GMT -05:00 This study resource was shared via CourseH Powered by TCPDF () Marvin Hayes vSim Assignment Documentation Assignments 1. Document your findings related to the focused assessment regarding Mr. Hayes's stoma status, peristomal skin, abdominal and perineal incisions. - Mr. Hayes’ stoma appeared pink, moist, and round. There was stool leakage around around the stoma. The abdominal incision had no signs of infection or bleeding and the perineal incision had an abdominal pad with no drainage or signs of infection. 2. Document assessment findings related to gastrointestinal function, output from colostomy, and ability to advance current diet post surgery. - The patient had normal bowel soundsand the output from his colostomy was half full with brown liquid. His diet is to advance to a regular diet as tolerated. He should avoid swallowing large pieces of food to prevent any blockages at the opening of the stoma. Identify and document key nursing diagnoses for Mr. Hayes regarding his current condition. 3. Identify and document key nursing diagnoses for Mr. Hayes regarding his current condition. - Acute pain, impaired skin integrity, fluid volume deficit, risk for imbalanced nutrition: less than body requirements, risk for infection, impaired self-image 4. Referring to your feedback log, document all nursing care provided and Mr. Hayes's response to this care. - Vitals were taken: 19 breaths/min, HR 94 bpm, BP 131/85 mmHg, SpO2 95%, Temp 99 F, conscious state - Auscultation of the lungs and abdomen: clear breath sounds and normal bowel sounds - Abdominal incision was assessed: normal findings - Assessed allergies and pain: no allergies, pain level of 1 on scale of 0-10 - Patient’s ostomy was assessed and changed: half full, brown liquid - His perineal incision was assessed: normal findings - Incentive spirometer was utilized - Patient teaching was provided for: coughing and using the incentive spirometer, ostomy care, and diet. 5. Document all patient education regarding colostomy care, diet, and safety issues provided to Mr. Hayes, as well as his response to the teaching. - Ostomy care: the bag should be emptied when it is one-third to one-half full. The stoma should be bright red, moist, and round. The skin barrier prevents the stool from coming into contact with your skin and should be adjusted so it fits around the stoma. Remember that the skin always has to be completely dry before applying new appliances. - Diet: most patients return to a fairly normal diet. avoid swallowing larger pieces of leafy vegetables and good in general to prevent any blockages at the stoma opening. To reduce From vSim for Nursing | Fundamentals. © Wolters Kluwer This study source was downloaded by from CourseH on :23:54 GMT -05:00 This study resource was shared via CourseH gas, don’t eat fast or use straws. Any foods that you know increase gas should be avoided. Asparagus, fish, and spiced food can increase odor, yogurt can help to reduce odor. - Incentive spirometer: this device can help with deep breathing exercises and increase ventilation to all areas of the lung. It also helps to loosen and mobilize secretions. 6. Document your handoff report in the situation-background-assessment-recommendation (SBAR) format to communicate Mr. Hayes's future needs. - Mr.Hayes just underwent a laparascopic abdominal perineal resection with a permanent sigmoid colostomy 3 days ago for rectal cancer - He experienced weight loss, increasing fatigue, and narrowing stools with blood, which led to the diagnosis of rectal adenocarcinoma - His vital signs were stable with a saturation of 94%-97%. Pian level is at 1 after pain medication was administered an hour ago. The colostomy appliance is an open ended pouch attached to a skin barrier. The stoma is red and moist with liquid, brown stool output. The three small abdominal incisions are open to air. There is a clean pad covering the perineal incision. Mr.Hayes has been up and ambulating and is taking full liquids. - It is time for his morning assessment. Assess his colostomy, empy his pouch, if necessary he can advance to a regular diet as tolerated. Prepare him for discharge in 1-2 days. From vSim for Nursing | Fundamentals. © Wolters Kluwer This study source was downloaded by from CourseH on :23:54 GMT -05:00 This study resource was shared via CourseH Powered by TCPDF () Marvin Hayes Guided Reflection Questions Opening Questions How did the simulated experience of Marvin Hayes’s case make you feel? I felt very overwhlemed because the time kept running out initially. There were so many times I needed to replace my gloves or provide education and lacked the time to fit those things in. By the end though I was more confident after being able to complete it successfully. Talk about what went well in the scenario. I was sure to maintain safety precautions and hygiene when checking the patients ostomy pouch and incisions. I also was adinmant to provide patient education on diet, colostomy care and the incentive spirometer. Reflecting on Marvin Hayes’s case, were there any actions you would do differently if you were to repeat this scenario? If so, how would your patient care change? I think reflecting back I would be mindful of hand washing and changing gloves/washing hands between quite different tasks assuming we are avoiding transimission of infection from him to me and me to him or any health care acquired-associated infection. Scenario Analysis Questions PCC What priority problem(s) did you identify for Marvin Hayes? The priority problem I identified for this patient was maintaining the ostomy pouch. The pouch was full and needed to be changed to prevent infection and pressure on the skin barrier PCC What potential problems could arise due to the newly placed colostomy? Potential problems that would arise are leaking of the colostomy, skin integrity/dehiscence of the incisions or ostomy, and possibly infection. PCC Discuss what type of diet would be appropriate for Marvin Hayes.  The Scenario Analysis Questions are correlated to the Quality and Safety Education for Nurses (QSEN) competencies: Patient-Centered Care (PCC), Teamwork and Collaboration (T&C), Evidence-Based Practice (EBP), Quality Improvement (QI), Safety (S), and Informatics (I). Find more information at: From vSim for Nursing | Fundamentals. © Wolters Kluwer. This study source was downloaded by from CourseH on :20:20 GMT -05:00 This study resource was shared via CourseH The type of diet that would be appropriate for Marvin would probably be an almost normal diet. He should avoid using a straw to help pre-vent gas. Large leafy vegetable should also be kept to a minimum to prevent blockages at the stoma. Many foods such as asparagus and fish will increase the odor while yogurt will limit it. Tolerating liquids and introducing new foods in slowly. PCC/T&C Discuss the importance of peer support groups with other adults with colostomies. Peer support groups would allow patients who also have colostomies to share their feelings and be able to ask questions in an environment where everyone shares a similar background or diagnosis. Peer support groups may help patients gain confidence and help them cope adequately with their new colostomy placement. EBP Explain why it is important to measure the stoma at least once a week for the first 6-8 weeks after surgery. The stoma may decrease in size over the six to eight week period after surgery. It is important to measure it in order to ensure the right fit for the opening of the pouch according to the size of the stoma. It is also important to measure the stoma to note any inflammation or signs of infection. T&C What other interprofessional team members should be involved in Marvin Hayes’s care? Other interprofessional team members that should be involved in Marvin Hayes’s care are other nurses, primary care physician, dietician, social worker, and pastor. I Cite one source that you could give to Marvin Hayes that would provide more information on colostomy care and resources. Concluding Questions Describe how you would apply the knowledge and skills that you obtained in Marvin Hayes’s case to an actual patient care situation. I feel like this scenario gave me a better understanding of patients post operatively and particularly with ostomy care. I would apply the knowledge from Marvin Hayes case to better educate the patient with colostomy care From vSim for Nursing | Fundamentals. © Wolters Kluwer. This study source was downloaded by from CourseH on :20:20 GMT -05:00 This study resource was shared via CourseH and what they are feeling about this new change. Along with that I would contact other interprofessional team members to best serve this patient and his needs. From vSim for Nursing | Fundamentals. © Wolters Kluwer. This study source was downloaded by from CourseH on :20:20 GMT -05:00 This study resource was shared via CourseH Powered by TCPDF () vSim ISBAR ACTIVITY STUDENT WORKSHEET Name: Alexandra McQueen Patient: Kim Johnson Date: 06/08/2021 106/108 INTRODUCTION Alexandra McQueen, LPN, Rehabilitation Unit 0800 Your name, positon (LPN), unit you are working on SITUATION Kim Johnson, 26-year-old, F, Thoracic T8 Spinal cord Injury Patent’s name, age, specific reason for visit BACKGROUND Kim has complete spinal cord injury at the T8 level. Bullet penetrated spinal column with no injury to visceral organs. She was admitted yesterday. Current orders vitals q8h Omeprazole 40 mg PO daily 0900, enoxaparin sodium 40mg SQ daily 0900, Oxybutynin 5mg ER PO daily 0900, Docusate Sodium 100mg PO once daily at 2200. PT is scheduled for 1030. Diet is reg with high fiber. Activity is out of bed to chair, I&O every 8hrs, Antiembolism stockings, intermittent catheterization every 4 hours, Bladder scan before catheter. Patent’s primary diagnosis, date of admission, current orders for patent ASSESSMENT Kim is alert and oriented. Normal skin elasticity Chest had normal sensation for temp., noxious, tactile stimuli of the chest. Breathing 20bpm, chest moving equally. for temp., noxious, or tactile stimulus, reflexes absent in both legs. Breath sounds were clear and equal bilaterally. HR and RR were reg. No murmur. LABS are WNL BP 126/84, radial and pedal pulses were strong 90bpm reg., pt reports no pain, temp. 98F, O2 96%, HR 90, RR 19 bpm equally, Cap. Refill -2 sec. Intermittent catherization Output was 354mL of urine. Patient teaching was done on Bladder management and I & O. Abdomen had no sensation for temp., noxious, or tactile stimuli subcostal, reflexes absent. Arms strength WNL legs have no sensation No difficulty breathing, mucous membranes showed no signs of dehydration. Current pertnent assessment data using head to toe approach, pertnent diagnostcs, vital signs RECOMMENDATION Vitals q8h, intermittent catherization q4h, Reposition q2h Discharge teachings or pt education Med admin @ 0900 Any orders or recommendatons you may have for this patent- TOP 3 most important things to pass on. Then anything you were not able to get to This study source was downloaded by from CourseH on :03:04 GMT -05:00 This study resource was shared via CourseH This study source was downloaded by from CourseH on :03:04 GMT -05:00 This study resource was shared via CourseH Powered by TCPDF ()