vSim ISBAR Student Activity Worksheet

vSim ISBAR Student Activity Worksheet

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.”

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.”

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

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).

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.