DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS)
ANTICIPATED PHYSICAL FINDINGS
ANTICIPATED NURSING INTERVENTIONS
vSim ISBAR ACTIVITY STUDENT WORKSHEET | |
INTRODUCTION | |
Your name, position (RN), unit you are working on | |
SITUATION | |
Patient’s name, age, specific reason for visit | |
BACKGROUND | |
Patient’s primary diagnosis, date ofadmission, current orders for patient | |
ASSESSMENT | |
Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs | |
RECOMMENDATION | |
Any orders or recommendations you may have for this patient |
PATIENT EDUCATION WORKSHEET |
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE |
MEDICATION:CLASSIFICATION:PROTOTYPE: |
SAFE DOSE OR DOSE RANGE, SAFE ROUTE |
PURPOSE FOR TAKING THIS MEDICATION |
PATIENT EDUCATION WHILE TAKING THIS MEDICATION |
Date: Student Name: Assigned vSim:
Initials: Age: M/F:Code Status: | Diagnosis:Length of Stay: Allergies: | HCP:Consults: | Isolation:Fall Risk: Transfer: | IV Type: Location:Fluid/Rate: | Critical Labs: | Other Services:Consults Needed: |
Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: |
Health History/Comorbities (that relate to this hospitalization): |
Shift Goals/ Patient Education Needs: 1.2.3.4. |
Path to Discharge: |
Path to Death or Injury: |
( Clinical Worksheet )
Alerts:What are you on alert for with this patient? (Signs & Symptoms)1.2.3.What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?)1.2.3.List Complications may occur related to dx, procedure, comorbidities:1.2.3.What nursing or medical interventions may prevent the above Alert or complications?1.2.3.4. | Management of Care: What needs to be done for this Patient Today? 1.2.3.4.5.6.Priorities for Managing the Patient’s Care Today1.2.3.4.What aspects of the patient care can be Delegated and who can do it? |
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