NURSING > EXAM > Clinical Worksheet henry williams part 2,WELL EXPLAINED GRADED A. (All)

Clinical Worksheet henry williams part 2,WELL EXPLAINED GRADED A.

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Date: 6/5/2020 Name: Brandi Griffin Assigned vSim: Henry Williams part 2 Initials: H.W Age:69 M/F: M Code: Full Diagnosis: COPD exacerbatio n Length of Stay: 5 days Allergies: Penicillin HCP: Unknown Consults: RT Isolation: none Fall Risk: Moderate Transfer: Pulmonary rehab IV Type: N/A Location: N/A Fluid/rate: N/A Critical Labs: N/A Other Services: None Consults Needed: Social services nutrition is your patient in the hospital? (Answer in your own words and include Hx of present illness): Pt admitted for SOB. Pt has hx of COPD and CAD and has anxiety due to wives worsening condition with her memory. Health History/Comorbidities (that relate to this hospitalization) Hx of COPD and CAD Shift Goals/Patient Education Needs: 1. Pt will verbalize feelings of health problems wife is having 2. Pt will be educated about discharge instructions 3. Pt will remain free of respiratory distress 4. Pt will be educated on use of medications after discharge Path to Discharge Pt being discharged to pulmonary rehab after geriatric assessment and sleep assessment are done Path to Death or Injury Pt not on path to death or injury Alerts: What are you on alert for with this patient? (S/S) 1. Signs of depression 2. Signs of impaired sleep 3. Signs of respiratory distress What assessment will you focus on for this patient? (how will I identify the above S/S)? 1. Geriatric depression scale 2. Pittsburg sleep activity index 3. Vitals/ head to toe What complications that may occur related to dx, procedure or Comorbidities 1. Suicide 2. Caregiver fatigue 3. COPD exacerbation What nursing or medical interventions may prevent the above alert or complications? 1. Listen to pt concerns 2. Complete assessments accurately 3. Complete vitals prior to discharge 4. Give resources for pt to have about avoiding caregiver fatigue Management of Care: What needs to be done for this patient today? 1. Geriatric depression scale 2. Pittsburgh sleep activity index 3. Medication reconciliation 4. Call rehab center 5. Vitals 6. Respiration assessment Priorities for managing the patients care today 1. Rehab assessments 2. Pt education of next steps 3. Paperwork ready for rehab 4. Pt education of use of medications What aspects of the patient care can be delegated and who can do it? Vitals can be checked by UAP

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