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VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX TEMPLATES NEED TO BE ANSWERED BASED ON CASE SCENARIO CASE SCENARIO INFO BELOW: PATIENT: WW 78 years old/ full code/ allergies aspirin/ 143 lbs 4/19 0930 Nursing Note: Client is admitted to the long-term care facility for therapy. She states she just needs some help until her leg heals. She had a left tibia repair 10 days ago. Physical therapy to evaluate her later today. She was transferred from the hospital via ambulance. Both of her children are currently with her at the bedside. 4/19 0930 Neuro/Cognitive: Client alert/oriented x 4. Speech is even and clear. Pupils 3 mm PERRLA. Obeys all commands. Short and long-term memory intact. Cardiovascular: S1 and S2 sound present. No murmurs, clicks, gallops—normal sinus rhythm on telemetry monitor in the 80s. No edema. Capillary refill less than 3 seconds. Respiratory: Shallow breathing. Lung sounds faint/absent in RLL, crackles in bilateral bases, ineffective, moist cough. 90% on room air. Gastrointestinal: Bowel sounds are present in all 4 quadrants. Abdomen soft, non-distended, non-tender. Last bowel movement this morning. Genitourinary: Reports no problems or pain with urination. Musculoskeletal: Moves all extremities freely. Has some stiffness in her hands. Lower left leg in walking boot and pain with left leg movement. 4/19 1545 Nursing Note: Client lethargic and fatigues easily. The client was noted to be febrile—SpO2 92% on room air. Placed on 2L/NC increased to 95%. Dr. Wallace was made aware. IV started with abx. The family was made aware of the current plan of care with antibiotic therapy to treat pneumonia. Family agreeable to plan of care. 4/20 0700 Nursing Note: Client alert/oriented x 4. States she slept well last night. She requests to complete her physical therapy today. Current vital signs in the chart. Client states she is in pain with both her chest and leg. She rates her pain 8/10 for her leg, and her chest is 4/10. She has not had any pain medication since last night at 2000. Date Temp HR RR BP SpO2 O2 4/19 1400 101.4 °F (38.4 °C) 98 21 100/55 95% 2L/NC 4/20 0630 100.4 °F (38 °C) 84 22 110/68 96% 2L/NC 4/19 1500 Prescriptions: Insert peripheral IV. Metformin 500 mg by mouth twice daily. Simvastatin 20 mg by mouth daily. Lisinopril 20 mg by mouth daily. Lab work: CBC, CMP x1, Vancomycin peak and trough levels. Vancomycin 1 g IV q12h. Ceftriaxone sodium 1 g IV q24h. Acetaminophen 650 mg by mouth q4-6h as needed for temp >38.2°C. Morphine 2 mg q4h as needed moderate-severe pain. Deep suctioning PRN. 2L/NC PRN. Titrate to keep SpO2 >95%. 4/19 0930 Medical History: Type 2 diabetes mellitus, hypertension, hyperlipidemia, osteoporosis, and hypothyroidism Surgical History: Left tibia repair 10 days ago, hysterectomy in 1981 4/19 1400 Home Medications: Lisinopril 20 mg by mouth daily Simvastatin 20 mg by mouth daily Calcium supplement by mouth once daily Metformin 500 mg by mouth twice daily Acetaminophen 650 mg by mouth q6h PRN for pain VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV Image transcription text Client Initials: Date of Care: Age/DOB: Admitting Diagnosis: Allergies: Comorbidities: BSA/BMI: Code Status: Planned Treatments/Procedures: Nu… Show more Image transcription text START of Shift (CJSim”*) Priorities (Complete after receiving REPORT AND reviewing the EHR connected to phase 1/Question 1 section) Recognize &am… Show more Image transcription text Answer these questions about today’s client: 1. Recognize Cues – Explain any assessment changes since the start of shift. 2. Analyze Cues – How are … Show more Image transcription text Clinical Debriefing Jet Fits ‘ ‘y caring for the client and answering the quest Answer these questions about today’s client: 1. Compore this client … Show more Image transcription text i Reflection Exercise (After providing care during the CiSimâ„¢ and complet ing the plan of care template for your questions focusing on the care you pro… Show more

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