Clinical Replacement Packet.docx 3 .docx - vSim ISBAR...

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vSim ISBAR Activity Student Worksheet Introduction (Your name, position (RN), unit you are working on) Mary Frometa Mental health unit Situation Patient’s name, age, specific reason for visit Li Na Chen is a 40-year-old Chinese female Reason for visit is Major Depressive Disorder Background Patient’s primary diagnosis, date of admission, current orders of patient Adm Dx: Major Depressive Disorder Date of admission: 4/17/2020 Orders - Laboratory tests: once every 12 hours, and then every day for 3 days Complete blood count Liver function tests (alanine aminotransferase [ALT], aspartate aminotransferase [AST], bilirubin [total and fractionated], alkaline phosphatase) Ammonia Prothrombin time with international normalized ratio Glucose Renal function studies (electrolytes, blood urea nitrogen, creatinine) Vital signs every 6 hours for the first 2 days until stable and then daily Encourage fluids Suicide precautions; observation every 15 minutes Unit safety check protocol Hamilton Depression Scale every other day Participation in unit milieu Activity: up and about Diet: regular Medications: Sertraline 75 mg orally every day at 09:00 for 5 days, and then decrease to 50 mg. On hold until restarted by the attending psychiatrist
Venlafaxine 37.5 mg orally every day at 09:00 for 5 days, and then increase to twice daily. On hold until restarted by the attending psychiatrist Assessment Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs The pill bottles for her recently prescribed acetaminophen and ibuprofen accompanying her appear empty. Mrs. Chen claims to have been using the medications as prescribed by the community clinic. Her husband reports that she may have taken approximately 6000 mg of acetaminophen and 4800 mg of ibuprofen. Acetylcysteine 7000 mg in 200 mL of 5% dextrose in water was given in the ER, and she underwent a gastric lavage; many recognizable pills were identified in the contents. Her vital signs are being monitored; the results of her last set of vital signs, which were taken in the ER, are as follows: temperature, 37°C (98.6°F); heart rate, 100 beats/min; respiratory rate, 20 breaths/min; and blood pressure, 110/70 mmHg. Blood for laboratory tests was obtained in the ER. The results are available in the chart. The acetaminophen level was 80 mcg/mL, and the ibuprofen level was 150 mcg/mL. They also assessed her depression in the ER using the Hamilton Depression Scale. The result is in her chart. Recommendation Any orders or recommendations you may have for this patient Depression or hostility monitoring and precautions Major depressive disorder patient care Major depressive disorder patient care Suicide precautions Suicide risk assessment, ambulatory care Suicide risk assessment, ambulatory care Patient Education Worksheet Name of medication, classification Medication: Sertraline hydrochloride
Classification: antidepressants Pharmacologic: selective serotonin reuptake inhibitors(SSRIs) Safe dose or dose range, safe route

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