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A Complete Solution to vSim for Nursing | Fundamentals

MRS. HERNANDEZ
1. Document your focused assessment of Mona Hernandez.
My focus assessment was on the Lung due to her diagnosis of Pneumonia
-Looked at: SpO2, Auscultation of the lung, Respiratory rate, Pain level
-The pain rating
-Sputum that is being produced (looked into the emesis basin)
-Temperature
-Difficulty of breathing

2. Document your assessment findings and any nursing interventions related to Mona Hernandez’s oxygenation.
Patient status – ECG: Sinus tachycardia. Heart rate: 119. Pulse: Present. Blood pressure: 142/86 mm Hg. Respiration: 22. Conscious state: Appropriate. SpO2: 87%. Temp: 101 F (38.2 C)
Due to her O2 saturation being so low and her verbalizing her she is having shortness of breath, Patient was helped to a high sitting position and oxygen therapy was started via nasal cannula at 2L to begin, and ultimately ending in 4L.

3. Document your education to Mona Hernandez regarding the purpose of, and how to use, the incentive spirometer.
Patient used an incentive spirometer, and this was indicated by order. Incentive spirometer provides visual reinforcement for deep breathing. It encourages the patient to maximize lung inflation and prevent or reduce atelectasis. In addition to this, it helps to support optimal gas exchange, and clearing and expectoration of secretions. Before using incentive spirometry equipment, the patient needs instructions on using the equipment properly.

4. Referring to your feedback log, document the nursing care you provided to Mona Hernandez and her response.
-I asked the patient if she had any difficulty in breathing, she replied: “Yes, for many days, but now it is worse.”

Description

KIM JOHNSON
(1) Document your initial focused urinary assessment of Ms. Johnson.
After obtaining Ms. Johnson vital signs, the patient was asked about her urine output and color. She stated that both were normal which would be confirmed by assessing the urine output following catheterization. The patient tolerated the straight catheterization and was educated on her bladder management program. The nurse also checked the skin turgor in which the skin snapped back quickly and did not tent. The patient reported no pain. The urine was clear and yellow with no odor, assessed after straight catheterization was complete. Patient does not have lower sensation so unable to assess burning or pain while urinating which are systems of urinary tract infection.

(2) Document Ms. Johnson’s straight catheterization procedure
The first step taken was applying glove in preparation for urinary catheterization, But the nurse believed that the tip was contaminated by Ms. Johnson leg, so the catheterization was discarded. The nurse then removed the gloves and performed hand hygiene. The gloves were put on and another catheterization was performed again as indicated by the order and discarded. The patient urine output was assessed, gloves were removed and another hand hygiene was performed.

Based on the step by step of the procedure, Ms. Johnson was first placed supine with her legs spread and knee bent. She then had her gentle cleansed and dried. After that, the nurse opened her catheterization kit sterilely and all the components. The catheter was then lubricated with the sterile syringe attached. Ms. Johnson was draped with the kit placed between her legs and the nurse donned with her sterile gloves. The nurse proceeded to cleanse the labia from far side, near side, then the middle, The swabs were discarded and spread the labia with her non dominate hand, and pick up the catheter with her dominate. They then proceeded to insert the catheter until urine began to flow. After the urine was expelled, the catheter was removed and the patient was cleansed again before being positioned for comfort.

(3) Record patient education provided for Ms. Johnson in the chart.
The patient received education on input and output, bladder management program, and activities, safety and fall risk. The patient was receptive of all education, and demonstrated a readiness for enhanced knowledge. The patient educations provided for Ms. Johnson in the chart are bladder management, urinary catheterization, intake and output, fall risk, use of pulse oximeter, positioning.

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Feedback Log
0:00 You arrived at the patients side.
0:00 You reviewed the patient information.
0:00 You reviewed the MAR.
0:00 You reviewed the orders.
0:00 You reviewed the intake and output.
0:00 You reviewed the diagnostics.
0:00 You reviewed the patient log.
0:00 You reviewed the clinical observations.
0:08 You washed your hands. To maintain patient safety, it is important to wash your hands as soon as you enter the room.
mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 97%. Temp: 99 F (37.2 C)
1:25 You introduced yourself. This was reasonable.
1:41 You identified the patient. To maintain patient safety, it is important that you quickly identify the patient.
1:50 You asked if the patient was allergic to anything. He replied:; No, I am not allergic to anything.
2:16 You educated the patient about activities, safety, and fall risk.
2:46 You educated the patient about body mass index.
mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 97%. Temp: 99 F (37.2 C)
4:12 You educated the patient about diagnostics.
4:54 You educated the patient about diet. This was reasonable.
5:24 You educated the patient about intake and output..
6:40 You educated the patient about positioning.
7:31 You educated the patient about tube feeding. This was reasonable.
12:19 You assessed the mucous membranes. This was reasonable.
12:51 You listened to the lungs of the patient. The breath sounds are clear and equal bilaterally.
13:14 You listened to the heart of the patient. This is reasonable. There were regular heart sounds without murmurs.
13:43 You listened to the lungs of the patient. The breath sounds are clear and equal bilaterally.
14:16 You looked for normal breathing. He is breathing at 12 breaths per minute. The chest is moving equally.
14:44 You attached the; pulse oximeter. It is a good idea to monitor the saturation and pulse here. This will allow you to reassess the patient continuously.
14:56 You checked the radial pulse. The pulse is strong, 85 per minute, and regular. It is correct to assess the patient’s vital signs.
15:41 You checked the temperature at the ear. The temperature was 99 F (37.2 C).
16:02 You measured the blood pressure at 120/72 mm Hg. It is appropriate to monitor the patient by measuring the blood pressure.
17:06 You checked the pedal pulse. The pulse is strong, 85 per minute, and regular.
17:30 You checked the radial pulse. The pulse is strong, 85 per minute, and regular.
19:07 You attached the pulse oximeter. ; It is a good idea to monitor the saturation and pulse here. This will allow you to reassess the patient continuously.
20:04 You assessed the patients neurological status.
mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
21:26 You checked the placement of the nasogastric tube. This was reasonable.
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22:39 You encouraged coughing.
23:42 You checked the placement of the nasogastric tube. This was reasonable.
24:06 You aspirated on the nasogastric tube. This was reasonable.
24:28 You flushed the nasogastric tube. This was reasonable.
25:13 You compared the medication label with MAR. This was reasonable.
25:22 A 5-tablet dose of pancrelipase was given orally. It is important to use the basic rights of medication administration to ensure proper drug therapy. This was indicated by order.
26:40 You compared the medication label with MAR. This was