Karen SIMChart Karen James is a 57-year-old female who was admitted to the medical-surgical unit from her primary care physician’s office for treatment and evaluation of persistent and worsening influenza. She has a past medical history of asthma as well as depression and anxiety. Patient History: Ms. James has had influenza symptoms for three weeks that have worsened in the past three days. She is currently experiencing a fever and chills, pleuritic chest pain, a productive cough with green sputum, and fatigue. Ms. James has been on a Zithromax Z-pack for the past five days without any improvement in symptoms. Her primary cause for admission at this time is her shortness of breath and severe coughing episodes, which turn into brochospasms. You have assumed care for Ms. James who is admitted to the medical-surgical unit for rehydration and management of respiratory distress. Orient yourself to the patient and health record by locating the following pieces of information within the System Assessment Report and Patient Teaching and type your answers in a Miscellaneous Nursing Note: 1). Run a report on all the System Assessments documented for the patient in the last 24 hours. You will need to go to Patient Charting > System Assessments > Show Saved Charting. What was documented for the respiratory effort? What was auscultated in the Lower Right Posterior lobe of the lungs? What was documented related to tissue perfusion? 2). What was the last documented temperature for Karen? 3). Does Ms. James use any sensory aides? 4) What does she rate her pain? 5) What is her MORSE Fall Risk Score? Review the client’s History and Physical, what indications can you see place this patient at risk for mobility issues or falls? [LEARNER ACTION: In a misc nursing note identify risks for mobility and falls. Explain her score on the MORSE scale.] When you are finished with this task, you may click Complete this Phase. Nursing Notes
1) Dyspnea/shortness of breath and shortness and breath on exertion Auscultation: Coarse Crackle Tissue Perfusion: Peripheral vascular, general: Warm extremities
2) Last documented temp. was 102.7
3) Wears contacts and wears glasses 4) No, she has no pain now therefore its 0 on the pain scale 5) Her fall risk is a 30
Phase 2: You enter Ms. James’ room to take her vital signs and obtain the following results: Temperature: 101.5 degrees Fahrenheit, oral… Pulse: 110, radial… Respirations: 20… Blood pressure: 144/68 left arm, sitting… Oxygen saturation: 99%, finger probe, room air… Document the vital signs in the vital signs tab on the Info Panel on the left (do not document in a misc. note). When compared to the patient’s admission vital signs, how is the patient’s temperature trending? Document your answer in a Miscellaneous Nursing Note. Under Basic Nursing Care: Choose 5 interventions you will perform at this time to make this client to increase safety. Only 5 as you will need to prioritize your cares. Try to find 5 related to Impaired Mobility. When you are finished with these tasks, you may click Complete this Phase.
1) The patient’s temp has increased since her admission vital signs 2) 5 Interventions:
-Fall-prevention education -Call light within reach -Toileting offered every 2 hours -Bed wheels locked -Orientation to the room