Yoa LI WSs.docx - Clinical Worksheet Date Student...

Clinical Worksheet
Date: ________________________ Student Name: ___America __________________________ Assigned vSim: _____Yoa li______________________
Initials: YL
Age: 26
M/F: M
Code Status: NA
Diagnosis:
Appendectomy
Length of Stay: na
Allergies: na
HCP:
Consults:
Isolation: na
Fall Risk:
Transfer: na
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):
Yoa Li had an appendectomy and was transferred to us with a PCA and is complaining of nausea and pain 7/10.
Health History/Comorbities (that relate to this hospitalization): Appendectomy
Shift Goals/ Patient Education Needs:
1. Monitor vital signs
2. Patient will be relieve from pain, and nausea
3. Educate patient on PCA
4. Educate patient on medications
Path to Discharge: Patient will be stable with vital signs WNR. Patient will understand the use of the PCA and medications.

Alerts:
What are you on alert for with this patient? (Signs & Symptoms)
1. Nausea
2. Pain