vSim ISBAR Student Activity Worksheet
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vSim ISBAR Student Activity Worksheet | |
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INTRODUCTION Your name, position (RN), unit you are working on |
“Hi my name is Ryann and I’m the RN working on the surgical unit.” |
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SITUATION Patient’s name, age, specific reason for visit |
“I’m taking care of Sara Lin, 18 year old female DOB 01/04/02 who had an emergency appendectomy 2 days ago. We’ve discontinued IV medications. She will be receiving oral medications and be discharged this afternoon.” |
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BACKGROUND Patient’s primary diagnosis, date of admission, current orders for patient |
“She came to the ED on 04/08/20 experiencing some nausea and vomiting with increased abdominal pain. She was taken to surgery that day and had an open appendectomy for a ruptured appendix. She has been stable since she’s been up here on the unit. Orders – · Discontinue IC ceftriaxone · Discontinue saline lock upon discharge Medications – · Oxycodone 5 mg PO Q4H PRN for pain · Acetaminophen 325 mg PO Q4H PRN for pain · Levofloxacin 500 mg PO daily for 7 days Activity – up as tolerated No heavy lifting, no driving May shower, cover incision with dry dressing. Discharge after 1500 Schedule follow up in Dr. Patel’s office in 1 week |
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ASSESSMENT Current pertinent assessment data using head to toe approach, pertinent diagnostic tests, vital signs |
Vital Signs – BP – 134/82 O2 – 98% Temperature – 99 F Pulse – 105 strong, equal bilaterally. S1 and S2 sounds heard. Strong and fast heart rate. Radial and Pedal pulses were strong and 98 equal bilaterally. Respirations – 20 – equal, labored, clear to auscultate. Remind her to use incentive spirometer. Bowel sounds – active Incision – no signs of redness, swelling, discharge, inflammation. No signs of infection. Pain scale – 6/10 after PO pain medication it was a 3 after 30 minutes. Skin turgor less than 3 seconds. No signs of dehydration. Skin is cool and moist – sweaty. Cap refill less than 2 seconds. Mucous membranes are clear no signs of tenderness, swelling, or drainage. PEARL – pupils are equal and reactive to light Neuromuscular assessment – ROM 5/5 all extremities. IV in right hand – no signs of redness swelling or infiltration. Blood analysis – WBC is 15 billion. (3.5-10). |
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RECOMMENDATION Any orders or recommendations you may have for this patient |
My recommendation is if before she leaves can we get an order for something that’ll help with her anxiety? She’s extremely anxious when she gets in too much pain and she’s anxious about the care she needs to do at home. |
Adapted from Wolters Kluwer vSim ISBAR Activity Student Worksheet
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