Edith Jacobson Documentation Assignments

1. Document your focused musculoskeletal assessment of Edith
   • A focused musculoskeletal assessment on a patient with a hip fracture would include assessing pain, joint tenderness, range of motion, and muscle
   • Pain in which she rated the pain a 2/10
   • ROM of legs, arms, feet and hands
     • Her L leg was weaker than her R, which was expected considering the fracture on L leg

2. Document your focused skin assessment of Edith
   • Tenderness on L hip area
   • Left leg was slightly short than the R leg
   • Elasticity in the skin
   • Skin colour was normal, and she was not sweating
   • Pulse was 90 bpm and regular
   • Skin temperature was normal
   • Skin turgor had a normal reutnr
   • Skin was intact and dry
3. Document the patient teaching that Edith Jacobson would need related to fall risk and prevention during her hospitalization and upon
   • Educated about activity, safety, and fall risk. It was explained that she is at risk for and therefore, she is instructed to use the call bell if she needs anything. She should not try to get up out of bed by herself, and if she feels dizzy or weak. It is important to let the nurse know if she wants to be repositioned in bed and to get out of bed.

4. Document the essential elements of proper body alignment for Edith Jacobson and include the specific supplies that would be
   • Edith needs to be kept in proper body alignment to prevent any additional injuries and to ensure that there wont be any breakdown of skin caused by prolong pressure on bony prominence.
   • Specific supplies would include:
     • Calling another nurse to assist me in repositioning patient to prevent any additional injuries for the patient
     • This will also help with proper body mechanism for myself, so I do not strain my back
     • Call bell

Edith Jacobson

Guided Reflection Questions

Opening Questions

How did the simulated experience of Edith Jacobson’s case make you feel? Talk about what went well in the scenario.

Reflecting on Edith Jacobson’s case, were there actions that you would do differently if you were to repeat this scenario? If so, how would your patient care change?

• Making sure to educate the patient about positioning
• Sitting the patient up right during medication administration of docusate sodium

What feelings were you experiencing during your interaction with Edith Jacobson?

• She was definitely a lot calmer than Sara Lin, but that’s also because she was not in that much pain
• I was definitely empathetic towards her

Scenario Analysis Questions𝗌

T&C Discuss the role of teamwork related to Edith Jacobson’s care.

• Physiotherapy to rehabilitate patient’s hip
• Radiologist:
  • To identify whether or not there is proper healing of the fracture
• Other nurses:
  • Help with repositioning
  • Providing care

T&C List some ways that teamwork and collaboration can be improved. Discuss how you would implement your suggestions.

• Teamwork could be improved through collaboration of patient goals to make a cohesive plan and ensure that everyone involved in the circle of care are working towards the goal
• Ensuring that the goal is client focused, so making sure that the patient is involved as well
• I would implement this suggestion by touching bases with the following departments about my suggestions as a nursing student and get their intake on my suggestions

S Describe your role in ensuring Edith Jacobson’s safety.

• Providing a call bell to the patient
• Evaluating patient’s understanding of my instructions
• Assess patient’s LOC
• Providing teaching strategies

EBP Discuss two evidence-based practices that you incorporated into your care of Edith Jacobson and how these practices impact patient outcomes.

• Repositioning q2h to prevent pressure ulcers
• Performing neurovascular assessments on lower extremities to identify and monitor an early detection of any complications such as blood clots

Concluding Questions

Describe how you would apply the knowledge and skills that you obtained in Edith Jacobson’s case to an actual patient care situation.

SBAR Instructions: Imagine you took care of Sara Lin on clinical day one and you are at the end of your shift. You are required to provide verbal report to the next nurse who is assuming responsibility of Sara Lin. Based on your VSIM experience specific to Sara Lin’s case, how would you formulate a change of shift report in a SBAR format. After you formulate the SBAR, you are required to present this TOA with the rest of the clinical group in the virtual meeting.

Time Plan Instructions:

Imagine that you had Sara Lin on clinical day one. Based on your knowledge of this Sara Lin’s current condition from VSIM, if you were to be assigned to this same client (Sara Lin) the next clinical day (clinical day two), how would you organize your day from 0730-1230.

Imagine your clinical day begins at 0730 where you are required to be on the unit at 0730. Your Time plan Must reflect your organization for the individualized care plan and include:

• Assessments
• Daily treatments
• Medication times
• Nursing orders/interventions from nursing care plan and other pertinent nursing interventions
• Documentation
• Reporting to staff

Your TIME PLAN Must be presented to the clinical group on VSIM day. For reference a sample Time Plan is posted on e-centennial under week 7 contents.

• Pathophysiological Concepts in relation to the admitting diagnosis

o Reason for admission to the unit. The associated pathophysiology of the diagnosis.

• A fracture of the hip (Figure 65-17) refers to a fracture of the proximal third of the femur, which extends up to 5 cm below the lesser trochanter. Fractures that occur within the hip joint capsule are called intracapsular fractures. Intracapsular (femoral neck) fractures are further identified by a name derived from specific locations: (1) capital (fracture of the head of the femur), (2) subcapital (fractures just below the head of the femur), and (3) transcervical (fractures of the neck of the femur). These fractures are often associated with osteoporosis and minor trauma.

• Manifestations of the admitting diagnosis

o Admitting diagnosis and the signs & symptoms associated with the diagnosis

The clinical manifestations of hip fractures are external rotation, muscle spasm, shortening of the affected extremity, and severe pain and tenderness in the region of the fracture site. Displaced femoral neck fractures cause serious disruption of the blood supply to the femoral head, which can result in AVN of the femoral head.

• Assessment Findings and Rationale

o The focused assessments that you performed in the VSIM Scenario and the findings to differentiate between normal vs abnormal (please use the head to toe assessment tool as a guide)

• Neuro

o Alert & oriented

• Respiratory
  • RR: 15bpm
  • Chest moving equally
  • SPO2: 957 (NORMAL)
• Cardiovascular
  • Radial and Pedal Pukse: 90
  • Regular
• Integumentary
  • Assessing for any dehydration
  • Ensuring that the site of the fracture has no signs of bruises, wounds
• Abdomen
  • Normal bowel sounds

• Pain

o Pain on L leg

o 2/10

• Pharmacological Knowledge

o Scheduled and PRN Medications (action, classification. indication, two common adverse effects and nursing implications)

• Morphine Uses:

To relieve moderate to severe pain SE:

• Drowsinesss
• Stomach pain and cramps
• Dry mouth
• Headache
• Nervousness
• Mood changes
• Small pupils
• Difficulty urinating or pain when urinating

• Enoxaparin Sodium: Uses:
• It is an anticoagulant medication (blood thinner). It is used to treat and prevent deep vein thrombosis (DVT) and pulmonary embolism (PE)

Side effects:

• Mild irritation
• Pain
• Bruising
• Redness
• Swelling at the injection site
• Fatigue
• Fever Nursing Implications:
• Assess for signs of bleeding and hemorrhage

o Bleeding gums, nosebleeds, unsualy bruising, black/tarry stools,

hematuria

STOCKINGS

designed to minimise the risk of blood pooling in your legs whilst you are ill and less able to move around than normal. If blood was to pool in your leg it may then form a blood clot.

• Boost circulation in her legs
• Support veins
• Diminish any leg swelling
• Prevent venous ulcers

Docusate Sodium

Classification:Laxative (Stool Softener)

Action:

• Increasing the amount of water the stool absorbs in the gut, making the stool softer and easier ot pass
• Prescribed for clients who have experienced a sudden change in lifestyle that puts them at risk for constipation, such as a surgery, injury, or conditions such as MI where straining during defecation should be

Side Effects:

• Stomach pain
• Diarrhea
• Cramping

Nursing Implications

• The nurse must assess the abdomen for distention and bowel sounds
• If there is absence of bowel sounds, peristalsis must be restored prior to laxative therapy

• Assess bowel patterns

o A client with a sudden, unexplained change in bowel patterns should be evaluated, as this change could indicate a serious condition such as colon cancer

• Also assess for esophageal obstruction, intestinal obstruction, fecal impaction, and undiagnosed abdominal

• Assess for the development of diarrhea and cramping; if diarrhea develops, the medication should be

• Priority Need and Diagnosis

o Based on your assessment and review of the client's condition, formulation of priority need (from the 11 needs guide) with rationale and nursing diagnosis (using a NANDA format)

Risk for injury related to L sided hip fracture shown by

Activity intolerance Risk for skin integrity

** Impaired physical mobility Risk for falls

• Nursing Intervention and Evaluation

o Based on your assessment and review of the client's condition, identify a minimum of five interventions. Similarly, please also identify five

evaluations specific to the interventions to indicate if they were to be successfully implemented.