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Make Up Julia Morales VSim Clinical Worksheet Activity
Medical-Surgical Nursing II (NSG 223)
Herzing University
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Date:8/22/2022 Student Name: Amari Wiley Assigned vSim: Make Up Initia l: JM Age: 65 M/F: F Code Status: DNR
Diagnosis: Stage 4 Lung Cancer Length of Stay: At Home Allergies: N/A
HCP:
Consults: Hospice
Isolation: Standard Fall Risk: Yes Transf er: N/A
IV Type: N/A Location: N/A Fluid/Rate: N/A
Critical Labs: N/A Other Services:
Consults Needed:
Why is your patient in the hospital/ being treated today? (Answer in your own words and include the History of present Illness)?: JM is a 65 year old female with a history of smoking for 10 years after college. The patient was diagnosed with stage 4 lung cancer and no longer wishes to recieve any treatment for her cancer. Health History/Comorbities (that relate to this hospitalization): The patient has stage 4 lung cancer after approximately 10 years of smoking prior to quitting years ago. The patient has no other known health problems or allergies contributing to condition. Shift Goals/ Patient Education Needs:
- Assess the patient and family’s understanding of hospice.
- Assess the patients and family’s understanding of durable power of attorney’s and advance directives.
- Assess the patient’s currentl pain level with and without medication
- Assess the patient’s family’s coping ability
Clinical Worksheet
- Assess vital signs for baseline records
- Assess heart, lung and bowel sounds
- Educate the family on the patient’s medication
- Educate the family the avaible community resources available to them during this process
- Evaluate the family’s ability to care for the patient during this transition time
- Evaluate the patient’s ability to care for themself
- Evaulate the family’s support system
- evaluate the family’s ability to administer medications as prescribed
- evaluate the family and patient’s need for home care equipment ex. hospital bed, walker, wheelchair, shower chair
- educate the family on the care’s needed by the patient
- Assess the patient’s appetite
- Educate the family on the changes they can expect as the patient declines in health
- educate on ways they can help reduce pain without medications
Ideal Path to Discharge: 1. The caregiver is able to provide the required care the patient needs 2. The caregiver is able to explain the purpose of the patients prescribed medications 3. The caregiver is able to administer the prescribed medications as ordered 4. The family will understanding the changes that accompanies the dying process 5. The family will verbalize their understanding of the patient’s wishes per their advance directive 6. The patient’s family will allow the patient to die as the patient requests Non-Ideal Path to Death: 1. The patient will experience pain throughout the dying process 2. The caregiver will be unable to provide the require care the patient needs a. The patient is transffered to the hospital or skill nursing facility to live out her remaining days
Clinical Worksheet
Alerts:
What are you on Alert for with this patient? (Signs & Symptoms)
Management of Care: What needs to be done for this Patient Today?
LOC a. alterned mental status b. confusion c. halluincations
Respiratory Status a. cessation of breathing b. bradypnea c. shallow breathing d. cheyne-stokes e. secretion buildup
Cardiovascular a. weak pulse b. irregular pulse c. cyanotic skin d. cessation of pulse
monitor and assess pain
assess vitals
assess LOC
educate family on how to administer medications
evaluate the family’s understand of the medication use
educate the family on the stages of the dying process
educate the family on the purpose of hospice
evaluate the family’s ability to care for the patient
evaluate the patient’s ability to care for herself
educate on ways to relieve pain
What Assessments will you focus on for this patient? (How will I identify the above signs & symptoms?) 1. Card a. heart rate/pulse b. heart sounds 2. Respiratory a. lung sounds b. respiratory rate 3. LOC
a. orientation
List Complications may occur related to dx, procedure, comorbidities:
Priorities for Managing the Patient’s Care Today
Card a. overdose from morphine b. death
Respiratory a. respiratory depression from morphine b. secretion buildup in airway
GI a. constipation i. decreased food and water intake b. nausea and vomiting c. pain d. fatigue
assess vitals
assess pain level and management a. monitor
assess the patient’s ability to help with cares
assess the caregiver’s ability to care for the patient
educate the patient and family on ways to relieve pain without medication a. mediation b. warm towels c. distraction
What nursing or medical interventions may prevent the above alert or complications?
What aspects of patient care can be Delegated and who can do it?
Respiratory a. assess respiratory status b. monitor respirations c. assess work of breathing d. assess lung sounds e. provide continuous monitoring to identify changes f. provide liquids to thin secretions as g. encourage and educate on the use of cough and deep breathing h. encourage movement and repositioning
Card
Breathing Exercises a. RN/LVN/LPN
Vitals a. certified nursing assistants b. licensed practical nurses/vocational nurses
bathing a. Certified nursing assistants b. licensed vocational/practical nurses c. home health nurse
Make Up Julia Morales VSim Clinical Worksheet Activity
Course: Medical-Surgical Nursing II (NSG 223)
University: Herzing University
