Clinical
A08
VSIM_templates.pdf.pdf
CONCEPT MAP WORKSHEET
DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
Dehydration Dehydration occurs when you use or lose more fluid than you take in, and your body doesn't have enough water and other fluids to carry out its normal functions. If you don't replace lost fluids, you will get dehydrated.
DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS)
PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS The patient is a 5-year-old female
who has had diarrhea and vomiting for the past 3 days and presented to the ER this morning with signs of dehydration.
Urine analysis: A urinalysis is used to detect and manage a wide range of disorders, such as urinary tract infections, kidney disease and diabetes. A urinalysis involves checking the appearance, concentration, and content of urine. Abnormal urinalysis results may point to a disease or illness. Patients result: Electrolyte balance: Electrolyte panel helps determine how the kidneys are working and where the electrolytes are.
● K +: 4.7 ● Na +: 145 ● Creatinine: 0.9 ● Cl -: 110 ● BUN: 20 ● HCO 3 -: 22
● Dry mouth and tongue ● No tears when crying. ● Sunken eyes and/or cheeks. ● Low electrolyte levels. ● Decreased urine output. ● Tachycardia. ● Weak thready pulse.
ANTICIPATED NURSING INTERVENTIONS ● Administer medications and fluids as ordered. ● Encourage the patient to drink more fluids. ● Monitor the patient intake and output. ● Educate the mother on the proper amount of fluid intake for the age group of the child
vSim ISBAR ACTIVITY STUDENT WORKSHEET
INTRODUCTION This is Brandi Griffin, RN calling from the pediatrics unit
Your name, position (RN), unit you are working on
SITUATION I am calling about Eva Madison, room 159. Her code status is full code. I am calling to update you on the patient’s status. I have just assessed the patient. Current vital signs: Blood Pressure: 82/65 Pulse: 190 beats/min and regular Respiratory Rate: 30 breaths/min; chest is moving equally Temp: 98.96 F O2 sat: 96% Pain Assessment: rated 2 on 0-5 FACES scale The patient’s increased pulse is concerning at this time.
Patient’s name, age, specic reason for visit
BACKGROUND The patient is alert and oriented to person, place, and time. The skin is quite cold and a tenting sign is present. The patient is not on oxygen at this time.
Patient’s primary diagnosis, date of admission, current orders for patient
ASSESSMENT The patient is improving, she has handled her treatments well ,she is interacting with her mother and myself, she is playing with her stuffed toy and watching TV. Current pertinent assessment data using head to toe
approach, pertinent diagnostics, vital signs
RECOMMENDATION The patient has shown improvements on her current plan of care and I do not think any changes need to be made at this time. Any orders or recommendations you may have
for this patient
Pharm 4 fun
PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Sodium chloride
CLASSIFICATION: Mineral and electrolyte replacement/supplement
PROTOTYPE: N/A
SAFE DOSE OR DOSE RANGE, SAFE ROUTE PO, IV (Children and Infants): Maintenance sodium requirements—3–4 mEq/kg/day (maximum: 150 mEq/day).
PURPOSE FOR TAKING THIS MEDICATION This is administered to treat or prevent sodium loss caused by dehydration.
PATIENT EDUCATION WHILE TAKING THIS MEDICATION ● Advise patients at risk for dehydration due to exposure to extreme temperatures when and how to
take NaCl tablets. Inform the patients that undigested tablets may be passed in the stool; oral electrolyte solutions are preferable.
● Explain to the patient the purpose of the infusion.
C lin
ic al
w or
ks he
et
D at
e: 0
3/ 4/
20 21
St
ud en
t N am
e: B
ra nd
i G rif
fin
As si
gn ed
v Si
m :
Ev a
M ad
is on
In iti
al s:
E. M
A
ge : 5
M /F
: F em
al e
C od
e St
at us
: Fu
ll co
de
D ia
gn os
is :
D eh
yd ra
tio n
Le ng
th o
f S ta
y:
24 h
ou rs
A
lle rg
ie s:
N KD
A
H C
P: P
rim ar
y ca
re p
ro vi
de r
C on
su lts
: N /A
Is ol
at io
n: C
on ta
ct pr
ec on
di tio
ns
Fa ll
R is
k: N
ot a
fa
ll ris
k Tr
an sf
er : N
/A
IV T
yp e:
P er
ip he
ra l
Lo ca
tio n:
B ra
ch ia
l v ei
n Fl
ui d/
R at
e: D
ex tro
se 5
% in
0.
45 %
n or
m al
s al
in e
at 6
2 m
L/ hr
C rit
ic al
L ab
s:
K +
4. 7
N a+
1 45
O th
er S
er vi
ce s:
N /A
C
on su
lts N
ee de
d: N
/A
W hy
is y
ou r p
at ie
nt in
th e
ho sp
ita l (
A ns
w er
in y
ou r o
w n
w or
ds a
nd in
cl ud
e th
e H
is to
ry o
f p re
se nt
Il ln
es s)
: Th
e pt
p re
se nt
ed to
th e
ER th
is m
or ni
ng w
ith s
ig ns
o f d
eh yd
ra tio
ns , s
he h
as h
ad d
ia rrh
ea a
nd v
om iti
ng fo
r t he
p as
t 3 d
ay s
an d
no u
rin at
io n
si nc
e 8:
00
PM y
es te
rd ay
. H
ea lth
H is
to ry
/C om
or bi
di tie
s (th
at re
la te
to th
is h
os pi
ta liz
at io
n) :
R ec
en t h
is to
ry o
f d ia
rrh ea
a nd
v om
iti ng
.
Sh ift
G oa
ls / P
at ie
nt E
du ca
tio n
N ee
ds :
1. In
cr ea
se p
t h yd
ra tio
n
2.
D ec
re as
e he
ar t r
at e
3.
Ke ep
th e
pa tie
nt c
al m
a nd
c om
fo rta
bl e.
4. Ed
uc at
e th
e pa
tie nt
o n
he r s
itu at
io n
(w ith
h er
p ar
en t’s
p er
m is
si on
a nd
a t a
n ag
e ap
pr op
ria te
le ve
l). E
du ca
te th
e pa
re nt
o n
th e
si tu
at io
n,
in te
rv en
tio ns
, m ed
ic at
io ns
, a nd
e xp
ec te
d ou
tc om
es .
Pa th
to D
is ch
ar ge
: Pt
is o
n pa
th to
d is
ch ar
ge
Pa th
to D
ea th
o r I
nj ur
y:
Pt is
n ot
o n
a pa
th to
d ea
th
C lin
ic al
w or
ks he
et c
on tin
ue d
A le
rt s:
W
ha t a
re y
ou o
n al
er t f
or w
ith th
is p
at ie
nt ?
(S ig
ns &
S ym
pt om
s)
1.
D ia
rrh ea
a nd
v om
iti ng
2. D
ro w
si ne
ss o
r d iz
zi ne
ss .
3.
In cr
ea se
in fe
ve r
W ha
t A ss
es sm
en ts
w ill
fo cu
s on
fo r t
hi s
pa tie
nt ?
(H ow
w ill
I i de
nt ify
th e
ab ov
e si
gn s
& Sy
m pt
om s?
)
1. M
on ito
r v ita
l s ig
ns .
2.
As se
ss le
ve l o
f c on
sc io
us ne
ss .
3.
M on
ito r i
nt ak
e an
d ou
tp ut
. Li
st C
om pl
ic at
io ns
m ay
o cc
ur re
la te
d to
d x,
p ro
ce du
re , c
om or
bi di
tie s:
1. H
yp ov
ol em
ia .
2.
Im pa
ire d
ki dn
ey fu
nc tio
n.
3.
Se iz
ur es
. W
ha t n
ur si
ng o
r m ed
ic al
in te
rv en
tio ns
m ay
p re
ve nt
th e
ab ov
e Al
er t o
r co
m pl
ic at
io ns
?
1. Ad
m in
is te
r m ed
ic at
io ns
a nd
fl ui
ds a
s or
de re
d
2. M
on ito
r l ab
v al
ue s
es pe
ci al
ly e
le ct
ro ly
te s
— s
uc h
as p
ot as
si um
a nd
s od
iu m
3. En
co ur
ag e
or al
in ta
ke a
s to
le ra
te d
4.
M on
ito r t
he p
at ie
nt s
I& O
M an
ag em
en t o
f C ar
e: W
ha t n
ee ds
to b
e do
ne fo
r t hi
s Pa
tie nt
T od
ay ?
1. R
es pi
ra to
ry a
nd c
ar di
ac m
on ito
rin g.
2. Vi
ta ls
s ig
ns a
nd a
ss es
sm en
ts
3.
Ke ep
in g
th e
pa tie
nt c
al m
a nd
c om
fo rta
bl e.
4. A
dm in
is te
rin g
m ed
ic at
io n
an d
flu id
s as
o rd
er ed
.
5. U
rin e
an d
st oo
l c ul
tu re
s.
6.
Ed uc
at in
g th
e pa
tie nt
a nd
p ar
en t.
Pr io
rit ie
s fo
r M an
ag in
g th
e Pa
tie nt
’s C
ar e
To da
y 1.
R es
pi ra
to ry
a nd
c ar
di ac
m on
ito rin
g.
2.
Vi ta
l s ig
ns a
nd a
ss es
sm en
ts .
3.
Ad m
in is
te rin
g m
ed ic
at io
ns a
nd fl
ui ds
a s
or de
re d.
4. U
rin e
an d
st oo
l c ul
tu re
s.
W ha
t a sp
ec ts
o f t
he p
at ie
nt c
ar e
ca n
be D
el eg
at ed
a nd
w ho
c an
d o
it?
Vi ta
ls s
ig ns
c an
b e
de le
ga te
d to
a ss
is ta
nt p
er so
nn el
, a nd
a ny
a la
rm in
g fin
di ng
s sh
ou ld
be
d ou
bl e
ch ec
ke d
by th
e R
N .
