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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