vSim for Nursing | Fundamentals CONCEPT MAP WORKSHEET: Sara Lin – Pain Management (completed)

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vSim for Nursing | Fundamentals CONCEPT MAP WORKSHEET: Sara Lin – Pain Management CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCE... SS) DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) Ultrasonography may show appendiceal inflammation. CT scan demonstrates suspected perforation or abscess. WBCs to see elevation = signs of infection PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS - Low-grade fever, diaphoresis, chills - Anorexia - Tachycardia - Fetal position to decrease pain - Guarding, voluntary and involuntary - Right lower quadrant tenderness - Rovsing sign - Psoas sign - Obturator sign ANTICIPATED NURSING INTERVENTIONS - pain assessment - transition Sara to oral medications - educate on incision care - educate on pain medication and antibiotics - educate on signs of infection - educate on activity restrictions - educate on surgical follow-up - Encourage the patient to ambulate - Encourage the patient to cough while splinting the abdomen, to breathe deeply, and to change positions frequently. - Auscultate for bowel sounds in all four quadrants. - Inspect the abdomen for distention - Perform surgical site dressing changes, as ordered. Also inspect surgical site dressing vSim ISBAR ACTIVITY STUDENT WORKSHEET INTRODUCTION Hi my name is Deep and I’m an RN on the surgical unit. Your name, position (RN), unit you are working on SITUATION Sara Lin is an 18 yo 2 days postoperative appendectomy patient. Patient’s name, age, specific reason for visit BACKGROUND She had a ruptured appendix and had an emergency appendectomy 2 days ago. She is to be discharged late this afternoon. I have administered her oral antibiotics for today and given her pain medication at 8:15 am Patient’s primary diagnosis, date of admission, current orders for patient ASSESSMENT Sara is alert and oriented, appropriate for age. Vital signs are 21R 105HR 99F 136/82 BP. She has been encouraged to use the incentive spirometer. She educated on incision care, pain medication and antibiotics, signs of postoperative infection, activity restrictions, and surgical follow-up. Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs RECOMMENDATION I recommend reassessment of vital signs as well as pain assessment. You should reminder her to use her incentive spirometer. Assess her knowledge on incision care, pain medication and antibiotics, signs of postoperative infection, activity restrictions, and surgical follow-up. Any orders or recommendations you mayhave for this patient PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: oxyCODONE CLASSIFICATION: Opioid analgesics PROTOTYPE: Opioids SAFE DOSE OR DOSE RANGE, SAFE ROUTE 5 to 15 mg immediate-release form or oral solution PO every 4 to 6 hours 10 mg extended-release tablets or 9 mg extended-release capsules PO every 12 hours PURPOSE FOR TAKING THIS MEDICATION Moderate to severe pain PATIENT EDUCATION WHILE TAKING THIS MEDICATION - Caution patient or caregiver of patient taking an opioid with a benzodiazepine, CNS depressant, or alcohol to seek immediate medical attention if patient experiences dizziness, light-headedness, extreme sleepiness, slowed or difficult breathing, or unresponsiveness. - Advise patient that drug increases risk of opioid addiction, abuse, and misuse, which can lead to overdose and death - instruct patient to take drug before pain is intense. - Explain assessment and monitoring process to patient and family. Instruct them to immediately report difficulty breathing or other signs or symptoms of a potential adverse opioid-related reaction. - Tell patient to take drug with milk or after eating. - Instruct patient or caregiver to keep drug out of the reach of children because accidental ingestion can result in a fatal oxycodone overdose. - tell patient to swallow extended-release tablets whole -Encourage patient to report all medications being taken, including prescription and OTC medications and supplements - Caution ambulatory patient about getting out of bed or walking - Advise patient to avoid alcohol use during therapy. - Tell patient not to stop drug abruptly. - Inform patient that urine drug testing and review of state prescription drug monitoring program will be done periodically. Clinical Worksheet Date: 6/24/20 Student Name: Deep Patel Assigned vSim: Sara Lin Initials: SL Age: 18 M/F: F Code Status: Full Diagnosis: Postoperative appendectomy Length of Stay: 3 days Allergies: no known HCP: Consults: Isolation: Standard Fall Risk: Transfer: IV Type: Location: Fluid/Rate: Critical Labs: WBCs Other Services: Consults Needed: Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: SL is postoperative 2 day from an appendectomy Health History/Comorbities (that relate to this hospitalization): Appendicitis Shift Goals/ Patient Education Needs: 1. Pain management 2. Education about medications and activity and safety after discharge 3. Administer oral antibiotics 4. education about incision care, signs of infection, and surgery follow up appointment Path to Discharge: Pt understands, medications, activity and safety risks, incision care, signs of infection, and surgical follow up appointment. The pt must also have a tolerable pain level before discharge. Path to Death or Injury: Pt is at risk for injury related to side effects of medication. Pt is also at risk for infection if incision care is not done correctly. Alerts: What are you on alert for with this patient? (Signs & Symptoms) 1. Severe pain 2. Infection of the surgical site 3. high respiratory rate, high heart rate, fever What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?) 1. Pain assessment 2. vital signs 3. inspection of dressing List Complications may occur related to dx, procedure, comorbidities: 1. infection is a major complication 2. severe pain 3. addiction to pain medication What nursing or medical interventions may prevent the above Alert or complications? 1. assessment of the dressing site 2. proper pain management 3. education about medications and incision site care 4. assessment of vital signs Management of Care: What needs to be done for this Patient Today? 1. Assessment of vital signs 2. Pain management 3. dressing site assessment 4. education to prepare for discharge = activity, safety, medications, incision site care, signs of infection, surgery follow up appointment. 5. encouraging coughing, and use of incentive spirometer 6. education on coughing and incentive spirometer Priorities for Managing the Patient’s Care Today 1. pain management 2. assessment of vital signs 3. dressing site assessment 4. education to prepare for discharge = activity, safety, medications, incision site care, signs of infection, surgery follow up appointment. What aspects of the patient care can be Delegated and who can do it? Could delegate vital signs reassessment to student or UAP [Show More]

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