vSim Health Assessment Case 3

vSim Health Assessment Case 3: Sara Lin

Documentation Assignments

1. Document your findings and Ms. Lin's reactions related to the focused assessment of her current pain status.

Ms. Lin states that her pain is a 3. She states that the pain started yesterday and has been continuous but is relieved by laying down and not moving. Ms. Lin shows visual expressions of pain upon moving and when palpating her abdomen. Further education about the pain scale ratings is advised.

2. Document your findings and Ms. Lin's reactions related to the abdominal assessment performed.

Ms. Lin grimaced when an abdominal palpation was performed on the lower right quadrant of her abdomen. Upon auscaltion of her abdomen, no abnormal bowel sounds were noted. When inspecting Ms. Lin’s abdomen there was slight distention.

3. Referring to your feedback log, document all nursing care provided and Ms. Lin's response to this care.

Basic nursing care practices including hand hygiene, introduction, patient check, and explanation of each assessment were received well by Ms. Lin. Ms. Lin gave simple, short answers to each question. Ms. Lin was questions about her pain characterisitcs, location, onset, duration, relief, and associated symptoms. She also gave short answers and rated her pain on a scale of 3. Ms. Lin described her pain as sharp, stabbing in her “stomach to the lower right”. Ms. Lin was asked when she had her last menstration, bowel movement, and urination. She replied with exact answers to each. Ms. Lin stated that she ate last around 2:00. Ms. Lin reports taking no medication when asked by the nurse. Ms. Lin stated no allergies. Inspection, palpation, and ausclation of the abdomen was performed after asking Ms. Lin’s permission. Ms. Lin remained quiet during abdominal assessment. Ms. Lin verbalized pain when her lower right abdomen was palpated. Emesis basin was checked and nothing was found. Patient handoff was initiated once comforting patient was completed. Sara received the comforting by the nurse kindly and deined she had anymore questions.

4. Document all patient teaching regarding assessments, care, medications, and safety issues provided to Ms. Lin, and her response to the teaching.

Ms. Lin was asked to give permission before the nurse performed any assessments. Ms. Lin allowed the assessment of her abdomen to commence without any hesitation. Ms. Lin rated her pain as a 3 on a 3 to 10 scale but verbalized pain during abdominal assessment. Ms. Lin required further education about the pain scale. Pain scale education was clear to Ms. Lin as she stated she had no further questions during the patient handoff.

5. Document your handoff report in the SBAR format to communicate Ms. Lin's future needs.

S – Patient complains of sharp, stabbing pain in her lower right abdomen. Patient states pain is better when she lays perfectly still. Patient states “the pain medication helps”. Ms. Lin is scheduled for an appendectomy and is being given pain medication intravensously.

B – Patient states that her abdominal pain started one day prior to hospital admission and has only been getting worse. She last ate at 2:00. Her last menstration was two weeks ago. Her last bowel movement was yesterday and her last urination was at the emergency room (time not verified). No prior surgery up to this point. No medications or allergies listed.

A – Patient states pain is level 3. Abdominal assessment performed. Patient states pain when lower right quadrant is palpated. Pain medication administered. Noted abdominal distention. Absence of nausea/vomiting. Patient respiration is abnormal: 18. Temeperature is abnormal: 100. Blood pressure abnormal: 117/70. SpO2 normal: 97%. Heart rate normal: 103. Sodium levels are elevated. WBC levels are elevated.

R – Keep patient on pain medication to manage comfort level. Educate patient about pain scale to ensure she knows how to accurately describe her pain. Inform patient about appendectomy surgery in preparation for the surgery.