DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS)
PATIENT INFORMATION
ANTICIPATED PHYSICAL FINDINGS
...
DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS)
PATIENT INFORMATION
ANTICIPATED PHYSICAL FINDINGS
ANTICIPATED NURSING
vSim ISBAR ACTIVITY STUDENT WORKSHEET
INTRODUCTION Aurora Vera primary nurse at the transitional care unit
Your name, position (RN), unit you are working on
SITUATION Vernon Russel is a 55-year-old male admitted to the hospital 2 weeks ago for a stroke with mild left hemiplegia.
Patient’s name, age, specific reason for visit
BACKGROUND Admitted on 07/31/2020,
Current Orders:
Current Orders:
Activity: Up with walker
Vital signs and neuro-checks per shift
Bedside blood glucose checks twice daily before breakfast and at bedtime
Hgb A1c1
Diet as tolerated
Labs: CBC, BMP, PT, and INR
Medications: Aspirin 81 mg orally daily, Metformin 500 mg orally twice daily, Losartan 50 mg orally twice daily, Nicotine patch 1 mg once daily for 6 weeks, Chlorthalidone 25 mg daily
Patient’s primary diagnosis, date of
admission, current orders for patient
ASSESSMENT Patient has limited range of motion of the left shoulder to 160 degrees. Limited range of motion of the left elbow to 140 degrees. Full range of motion of the other joints in the arms. Normal sensation for touch and pain on patient’s arms and hands. Active range of motion against gravity in the left arm. Active range of motion against full resistance in the right arm. 3 out of 5 strength in the left arm and hand grasp, and 5 out of 5 in the right arm and hand grasp. All skin free of lesions or scars; regular color and odor. Nails were smooth, clean, intact, with no signs of cyanosis or clubbing. Active motion against gravity in the left leg and active motion against full resistance in the right leg. Left hip flexion is limited to 80 degrees with full ROM in the other joints of the leg. Active ROM against no resistance in left foot and active ROM against full resistance in the right foot. the patient’s vital signs were as follows: BP: 144/84 HR: 90 bpm RR: 16 SpO2: 98% Oral temp: 99F.
Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs
RECOMMENDATION
Perform neuro assessment and vital signs per shift
Bedside blood glucose checks twice daily before breakfast and at bedtime
Medication as ordered by provider
Labs: CBC, BMP, PT, and INR
Patient will be educated on risk and prevention of falls.
Educate on the importance of passive range of motion exercises to increase mobility and circulation.
Physical therapy and Occupational therapy two times a day
Patient will be educated on how to manage symptoms or complications after stroke
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