vSim Health Assessment Case 9: Edith Jacobson
Documentation Assignments
1. Document your findings related to the focused assessment regarding Mrs. Jacobson’s
neurologic status. Include her responses to your assessmen
...
vSim Health Assessment Case 9: Edith Jacobson
Documentation Assignments
1. Document your findings related to the focused assessment regarding Mrs. Jacobson’s
neurologic status. Include her responses to your assessment.
Asked patient the year we are in and she stated 2021
Asked patient where she is and she stated she is at the hospital
Asked the patient today’s date and she stated the 28th
Asked patient what happened and she stated she fell last evening and hit her head
Asked patient if she was dizzy and she said “no, not now”
Asked patient if she can feel and move her toes and she stated yes to both
Asked patient if we can check how her pupils react to light using a penlight and she was
ok with it. The pupils were both round, 5mm in size, and reacting equally to light.
Asked patient to assess hair and scalp and she stated she still as some hair. Found that
hair is thinning and the scalp is dry. Checked patient’s eye opening and noticed she has
spontaneous opening of the eyes. We added 4 to the GCS score
Asked patient to move her arms and legs and patient obeyed verbal commands so we
added 6 to the GCS score
Asked patient if she was awake and she responded yes she is awake. The patient
converses and is oriented so we added 5 to the GCS score
GCS score of 15 indicates an optimal level of consciousness
2. Document your findings related to the Mini-Cog and falls assessments of Mrs. Jacobson.
Include her responses to your assessments.
Asked paitent if she has any pain and she stated she does but pain medication really helps
although any movement makes the pain worse
Patient states pain is in her left hip and it hurts to move and rates pain a 2
Patient states pain started after she fell
Explained to patient we will perform a cognitive Mini-Cog exam on her and asked her to
follow instructions. The mini-cog assessment showed normal cognitive function as
patient was able to repeat the words banana, sunrise and chair twice as well as draw a
clock the way we instructed
Asked patient if we can assess the skin around her pelvic area to make sure there are no
problems and found there are no lesions or scarring, normal color, odor, and skin
integrity. The patient agreed to this assessment
Asked patient if we can inspect her hips for color and symmetry because of her hip
injury. Patient stated this was fine. We found moderate swelling around the left hip area,
there is no discoloration but the left leg is a bit shorter than the right.
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We asked the patient if we can gently touch her hips to assess them and she asked us to be
careful with her left hip because it hurts. We found there is pain when lightly palpating
the left hip, there is moderate swelling around the left hip area but no masses or heat
3. Referring to your feedback log, document all nursing care provided and Mrs. Jacobson’s
response to this care.
Asked the patient if she needed anything for the pain and she replied “no it is not bad
now”
Nurse comforted the patient during intervention phase and she stated that it was very nice
of us
4. Document all patient teaching regarding assessments and safety issues provided to Mrs.
Jacobson, and her response to the teaching.
Educated the patient about activitie
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