Sherman Red Yoder - All Parts.docx - Sherman...

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Sherman “Red” Yoder – Part A Part 1: Plan of Care Concept Map (adapted from vSim template) Simulation Patient Overview Client summary: presentation, medical history and background, physical assessment findings, medications, diagnostics brief summary of pathophysiology and rationale for clinical manifestations Red is an 80-year-old male who lives alone, 20 miles from the nearest city. The patient has previously been diagnosed with type 2 diabetes (six months ago) and has recently began taking insulin. The nurse came to Reds’ house to assess and evaluate a wound that was caused by wearing shoes that were too tight. The toe was injured about three weeks ago. It is plausible that Red has developed peripheral neuropathy which is typically caused by diabetes. This causes loss of sensation and numbness to the extremities. In Reds’ case, he might have not felt in the injury on his toe and that is why he did not address it immediately. Red also lives alone so there was no was else in the household to bring his attention to the injured toe. The Assessment Anticipated Physical Assessment Findings additional focused assessment relevant cues (S&S) cues indicating need for immediate concern and rationale Anticipated Diagnostic Tests relevant cues (abnormal findings) additional tests to consider Peripheral neuropathy – numbness and loss of sensation in the feet Right toe wound Abnormal Values Part A : No diagnostic tests Additional tests to consider – monitoring of blood glucose x 4 times a day. Plan Anticipated Care Priorities Anticipated Nursing Interventions Monitor blood glucose levels and adhere to medication. Wound dressing. Feet inspection. Educate patient on: the importance of monitoring his blood glucose after meals, and adhering to the sliding scale dosage, daily inspection of feet with help of mirrors and family, how to apply wound dressings on his right toe to prevent further complications, information on diet and nutrition. Great importance must be placed on footcare. © Wolters Kluwer Health | Lippincott Williams & Wilkins
Diet and nutrition information. Sleep education. Assess independence in ADLs. ISBAR Worksheet (adapted from vSim) ISBAR Student Notes Introduction Your name, position (Nursing student), unit you are working on What is the purpose of this communication? Hello, my name is Ronit Patel. I am student RN with a home health agency. I will be giving you a report on Red Yoder. Situation What is happening at the moment? Patient’s name, age, specific reason for visit/admission Red Yoder is an 80-year-old male that is being seen at home for a right toe wound. Background What are the issues that led up to this situation? Patient’s primary diagnosis, date of admission, current orders The patient was diagnosed with type two diabetes six months ago. He has recently began taking insulin. Red suffered an injury to his toe three weeks ago. Up till now, he has been wearing tight shoes which progressively made his injury worse.

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