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Clinical WorksheetDate: ________________________ Student Name: ___America __________________________ Assigned vSim: _____Yoa li______________________ Initials: YLAge: 26M/F: MCode Status: NADiagnosis: AppendectomyLength of Stay: naAllergies: naHCP: Consults: Isolation: naFall Risk: Transfer: naIV 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): AppendectomyShift Goals/ Patient Education Needs: 1. Monitor vital signs2. Patient will be relieve from pain, and nausea3. Educate patient on PCA 4. Educate patient on medicationsPath 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.Nausea2.Pain