Clinical Simulation Documentation Donald Windanstaley Case Studies

Clinical Simulation Documentation 1. i-Human Patient Name: Donald Winstanley Student Name: Travisha Kelley 2. Date simulation completed: November 14, 2021 Date posted to Moodle: November 14, 2021 3. Patient Report/Data Age: 45 Allergies: NKA Date of admission: November 14, 2021 Admitting diagnosis: Comprehensive health assessment Admission related co-morbidities/history: (if available): Hx of Hypertension 4. Abnormal Lab Values (if listed for your i-Human patient) Abnormal Lab Value Normal Lab Value Comments-What do you think is causing the abnormal lab value? BMP UA Hemoglobin A1C CBC Lipid Profile Serum Poor diet/ lack of medication/smoking 5. Procedures/date/results: (if available): N/A 6. Patient Medications: (Include in chart below all medications administered by student. Also include all patient’s ordered MAR IV fluids, flushes, tube feeding, TPN, O2, etc.) Trade/Generic Name of Drug or IVs/Tube feeding/TPN/02, etc. N/A Dosage, Route, Frequenc y Therapeutic Classification Medication Status: Home/New/Hospita l Protocol/STAT dose Indications for use (Why are you administering this medication?) Nursing Considerations when administering this medication to this patient Plan of Care Section 7. Focused patient assessment: (Include focused patient assessment information that will support and explain your priority nursing diagnosis/problem. You will pull this from your iHuman assessment) 45-year-old male has come to clinic for comprehensive health assessment. Warehouse worker with no health insurance for the past three years. PT has never been hospitalized or had surgery. But has a Hx of untreated Hypertension. Patient is Alert and Oriented x 4. Patients’ memory in intact, though process is spontaneous and circumstantial without delusion. PT admits to drinking a few beers every now and then and smoking a pipe nightly. During assessment noted lungs clear to auscultation. Skin warm, intact, and dry. No Known allergies and full code. Patient is not agitated or hostile towards others. VS- T 98.4, BP 126/64, P 88, R20, O2 92% (RA) Pain 0/10. 8. Priority nursing diagnosis/problem: Need for Health Teaching due to unfamiliarity with hypertension treatment. 9. Measurable outcome: (Time frame=during my clinical. shift; this is different than being in clinical for 12 hours) By end of shift and after patient has received treatment patient verbalizes knowledge of the importance of frequent hypertension evaluation, treatments, and adhering to lifestyle changes. 10. Intervention(s): (List 3-4 interventions you would implement to help meet your measurable outcome) 1. Teach importance of self-evaluation of BP at routine intervals and adherence to the prescribed medication therapy. 2. Teach medication actions, administration times, side effects, adverse effects, and the importance of taking as prescribed. 3. Teach the importance of seeking medical evaluation if BP reading is greater than 180/120 mm Hg or less Evaluation: (Explain how the interventions would help with meeting the outcome.) 1. Frequent evaluation provides feedback on response to medication therapy and may help improve adherence to therapy. 2. Knowledge about the adherence to the prescribed regimen can lower morbidity and mortality risk and improve patient outcomes. 3. Severe hypertension can be life threatening compromising perfusion to vital organs. than 90/60 mm Hg, or if headache, dizziness, lightheadedness, or blurred vision Citation: (Swearingen & Wright All-In-One Nursing Care Planning Resource, 2019) Student Comments: Journal Score: ______ Instructor Comments: Grading Rubric for Simulation Journal Timeliness:  2 points Journal posted on time and spent 2 hours or more in simulation   1 point Journal posted after due date OR spent less than 2 hours in simulation. 0 points Journal not submitted Criteria:  4 points Clinical Journal criteria met (all 10 categories satisfactorily addressed and posting provides exemplar evidence that student has researched and applied material accurately)  3 points Clinical Journal criteria partially met (8-9 of the categories satisfactorily addressed and/or posting provides adequate evidence that student has researched and applied material accurately) 2 points Clinical Journal criteria partially met (6-7 of the categories satisfactorily addressed and/or posting provides limited evidence that student has researched and applied material accurately)  0 points Clinical Journal criteria not met (<6categories satisfactorily addressed and/or no evidence that student has researched/applied material accurately)