C

DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)

DIAGNOSTIC TESTS
(REASON FOR TEST AND RESULTS)
▪ Complete Blood Count - Measures for blood cell count including RBC, WBC, Platelets, Hb & HCT.. Since this pt. is post-operational, it is critical to monitor his blood levels after
surgery takes place to ensure there are no abnormalities, such as formation of a blood clot, anemia or a high WBC count indicating infection, which this pt. is at risk for all three
since he is diagnosed with MRSA & is on enoxaprin, an anticoagulant. The pts. Hb was 11 & his HCT was 36%, which are both low. His platelet level was at 198,000 & WBC's were
at 11,000 which are both within normal limits.
▪ Electrolyte Levels - Measures for any fluid or electrolyte imbalances in the body, such as potassium, calcium & sodium levels. Since this pt. is currently diagnosed with
osteoarthritis, it is best to monitor the pts. electrolyte levels to ensure there are no abnormal values or imbalances. This test is also useful for determining any secondary causes
of osteoarthritis. The pts. electrolyte levels were all within normal limits except for his Chloride level being low at 100, which could indicate dehydration . Another substance that
this test measures is blood urea nitrogen (BUN), which evaluates kidney function and is important for this pt. because he is on multiple medications which can damage the
kidneys over time if not monitored. The pts. BUN levels are all within normal range.
▪ Coagulation Screen Test - This test measures the current ability of the blood to clot & how long it takes to clot. Due to the pts. impaired mobility related to his post-operational
knee surgery the pt. is at risk for blood clotting & pressure injuries. The pts. coagulation screen test results were all within normal range.
▪ X-Ray Imaging: Shows joint or bone damage & any changes related to osteoarthritis.
PATIENT INFORMATION
J.G. is a 63 yr. old African American male who was a former athlete and is currently an accountant and is married. J.G. has had a history of osteoarthritis that has been worsening for the
past 10 years. J.G. has a history of hypertension & MRSA in which he was diagnosed 3 years ago when having surgery for hammer toe during his previous visit. He was admitted for
having a total right knee arthroplasty (TKA) performed and is now being closely monitored for his pain level, wound care and risk of infection. Due to his MRSA diagnosis, contact
precautions must be initiated during his stay to prevent infection from occurring.
ANTICIPATED PHYSICAL FINDINGS
▪ Limited Mobility in lower right extremity
▪ Limited or abnormal range of motion (ROM) in lower right extremity
▪ Small incision on right knee due to arthroplasty procedure
▪ Knowledge deficit on wound care
▪ Inability to move or bear weight on affected knee
▪ Impaired ability to ambulate
▪ High BP due to hypertension
▪ Higher WBC count due to being post-op and susceptibility to infection
ANTICIPATED NURSING INTERVENTIONS
▪ Assess wound dressing every 2 hours, document any abnormalities and change dressing as needed.
▪ Reposition pt. every 2 hours to prevent pressure injuries and blood clot formation.
▪ Have pt. use incentive spirometer 10x every 1 hr to improve respiratory inspiration.
▪ Perform a Pain Assessment every 4 hours to determine level of pain before and after medications have been given.
▪ Monitor vital signs (BP, Oxygen, Pulse, Temperature) and lab values every 4 hours.
▪ Monitor I&O and make sure pt. hydration is maintained.
▪ Perform passive ROM exercises with pt. to assess musculoskeletal function.
vSim ISBAR ACTIVITY
INTRODUCTION
Your name, position (RN),
unit you are working on
SITUATION
Patient’s name, age, specific reason
for visit
BACKGROUND
Patient’s primary diagnosis, date of
admission, current orders for patient
ASSESSMENT
Current pertinent assessment data
using head to toe approach,
pertinent diagnostics, vital signs
RECOMMENDATION
Any orders or recommendations
you may have for this patient
STUDENT WORKSHEET
My name is Karina Rodriguez and I am a Registered Nurse. I currently work on the Orthopedic
Unit.
The pts. name is Jared Griffin. He is a 63-yr-old African American male who was admitted into the
hospital yesterday morning to have a total right knee arthroplasty (TKA) performed due to being
diagnosed with osteoarthritis. He is currently in post-operation and under contact precautions due
to his diagnosis of MRSA.
The pt. was admitted yesterday on 10/13/2020 at 1836. The pts. primary diagnosis is osteoarthritis
accompanied by mild hypertension and MRSA. A nasal swab was done during a pre-op check
which came back positive for MRSA. Pt. has had a 10 year history of worsening osteoarthritis and
was diagnosed with MRSA after having surgery performed for a hammertoe during his previous
visit. He is currently under contact precautions and on a full liquid diet. The surgeon discontinued
the wound drainage & IV fluids at 0700.
Pts. vital signs were taken at 0815 and are all within normal limits. Pt. pulse ox is at 97%, BP is
136/80 and was taken on the left upper arm, HR is 80 bpm, temperature is at 98F and RR is 15
breath/min with no adventitious sounds. Capillary refill is less than 2 secs. Pedal pulse is 80 bpm.
Pt. is oriented x4 & has a codeine allergy. Pt. was reporting constant burning & piercing pain on
knee site on previous shift. Pts. pain level was reassessed at 0810 & now reports a pain level at 2
out of 10. Lower extremities were assessed & skin is clean, dry & intact. Pt. is currently wearing anti-
embolism stockings. Pt. right knee can be bent to about 75 degrees. Pt. wound dressing is covering the
skin lesion on right lower leg & is clean, dry & intact. An incentive spirometer was used by the pt. at
0823 and was educated on its use.
The pt. should stick with the discontinuation of IV therapy due to heightened risk of infection and
should stay hydrated. The pt. should be reassessed for his pain level and re-positioned every 2
hours. The pt. should be set up with a physical therapy consult before his discharge to provide any
necessary assistive devices. The pt. should be assessed for any pressure injury formations and
checked for circulation in lower extremities every hr. Pts. vital signs and lab values should be
continued to be monitored every 4 hrs & I&O every hr. The incentive spirometer should be used 10
times every hour to ensure healthy respiratory rate. Assist the pt. in dangling his feet over the bed
tonight to improve circulation. Dressing should be changed every day & assessed. A neurovascular
and respiratory assessment should be performed every 4 hrs. Pt. should be taught hand hygiene and
standard precautions to prevent infection.
 PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION:
Enoxaparin sodium 40 mg Subcut daily q24hr
CLASSIFICATION:
Therapeutic: anticoagulants
Pharmacologic: antithrombotics
PROTOTYPE:
Heparins (low molecular weight)
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
For pts. undergoing knee replacement surgery: Subcut (Adults) 30 mg every 12 hr starting 12-24 hr postop for 7-10 days Subcut 40 mg daily is not
considered to be a safe dose. Subcutaneous route is a safe route.

PURPOSE FOR TAKING THIS MEDICATION

▪ Prevention of venous thromboembolism (VTE), DVT and/or pulmonary embolism in surgical or medical pts.
▪ Treatment of DVT with or without pulmonary embolism (w/ warfarin)
▪ Treatment of acute ST-segment elevation MI (w/ thrombolytics or percutaneous coronary intervention).

PATIENT EDUCATION WHILE TAKING THIS MEDICATION

▪ Instruct pt. in correct technique for self injection, care & disposal of equipment.
▪ Advise pt. to report any symptoms of unusual bleeding/bruising, dizziness, itching, rash, fever, swelling or difficulty breathing to HCP immediately.
▪ Instruct pt. not to take aspirin or NSAIDs without consulting HCP while on therapy.

Resource: Davis’s Drug Guide

 PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION:
Docusate calcium (dioctyl calcium sulfosuccinate) 50 mg PO daily q12h
CLASSIFICATION:
Therapeutic: laxatives
Pharmacologic: stool softeners
PROTOTYPE:
Kaopectate Stool Softener, Kao-TIn
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
Safe dose and route for adults is 240 mg PO once daily. 50 mg PO daily is considered to be a safe route & dose for this pt.

PURPOSE FOR TAKING THIS MEDICATION

▪ Promotes incorporation of water into stool, resulting in softer stool.
▪ Promotes electrolyte & water secretion into the colon.
▪ Softening & passage of stool.

PATIENT EDUCATION WHILE TAKING THIS MEDICATION

▪ Advise pt. that laxatives should be used for short-term therapy only or else it may cause electrolyte imbalance & dependence.
▪ Encourage pt. to use other forms of bowel regulation such as, increasing fiber in diet, increasing fluid intake (6-8 full glasses/day) & increased
mobility once fully healed from surgery.
▪ Instruct pt. to avoid straining during bowel movements.
▪ Advise pt. not to use laxatives when experiencing abdominal pain, nausea, vomiting or fever.
▪ Advise pt. not to take docusate within 2 hrs of other laxatives.

Resource: Davis’s Drug Guide

PATIENT EDUCATION WORKSHEET

 NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION:
Dextrose 5% sodium chloride 0.45% 60 ml per hr Intravenous (IV)
CLASSIFICATION:
Therapeutic: caloric solution
Pharmacologic: carbohydrates
PROTOTYPE:
N/A
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
Safe dose and route for adults using dextrose for hydration as a 5% solution is 0.5-0.8 g/kg/hr IV. Based on the pt. weighing 97.5 kg, this is considered to
be a safe dose & route.
PURPOSE FOR TAKING THIS MEDICATION
▪ Lower concentration (2.5%-11.5%) injection provides hydration & calories.
▪ Provides calories due to pt. being on a full liquid diet.

PATIENT EDUCATION WHILE TAKING THIS MEDICATION

▪ Explain the purpose of dextrose administration to pt.
▪ Advise pt. to call their healthcare professional or caregiver if the catheter, needle or IV tubing becomes blocked or if the flush or IV medicine is not
flowing normally.

Resource: Davis’s Drug Guide

PATIENT EDUCATION WORKSHEET

NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION:
Clindamycin hydrochloride 600 mg intravenous Piggyback (IVPB) q8h x3
CLASSIFICATION:
Therapeutic: anti-infectives
PROTOTYPE:
Antibiotics

SAFE DOSE OR DOSE RANGE, SAFE ROUTE

The safe dose & route for adults for most infections is: 300-600 mg every 6-8 hr or 900 mg every 8 hr. 600 mg IVPB is considered to be a safe dose &
route for this pt.
PURPOSE FOR TAKING THIS MEDICATION
▪ Treatment of skin & skin structure infections, respiratory tract infections, septicemia, osteomyelitis, gynecologic infections, intra-abdominal
infections & endocarditis prophylaxis.

PATIENT EDUCATION WHILE TAKING THIS MEDICATION

▪ Instruct pt. to notify HCP immediately if experiencing diarrhea, abdominal cramping, fever or bloody stools occur & not to treat with antidiarrheals
w/o consulting HCP.
▪ Advise pt. to report signs of superinfection (furry overgrowth on the tongue, anal itching or discharge).
▪ Instruct pt. to take medication ATC at evenly spaced times & to finish completely as directed, even if feeling better. Do not double dose.
▪ Inform pt. that bitter or metallic taste occurring with IV administration is not clinically significant.
▪ Instruct pt. to notify HCP if no improvement occurs within a few days.

Resource: Davis’s Drug Guide

PATIENT EDUCATION WORKSHEET

NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION:
Hydrocodone bitartrate-acetaminophen 10/325 mg Oral (PO) PRN q4h
CLASSIFICATION:
Therapeutic: opioid analgesics
Pharmacologic: opioid agonists/nonopioid analgesic combinations
PROTOTYPE:
Analgesics
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
Safe dose and route for adults for analgesic use is 2.5-10 mg PO every 3-6 hr PRN. 10 mg PO PRN q4h is considered to be a safe dose & route for this
pt.
PURPOSE FOR TAKING THIS MEDICATION
▪ Management of moderate to severe pain.

PATIENT EDUCATION WHILE TAKING THIS MEDICATION

▪ Advise pt. to take medication as directed & not to take more than recommended amount due to possible severe & permanent liver damage.
▪ Instruct pt. on how & when to ask for & how to take medication.
▪ Advise pt. that hydrocodone is a drug with known abuse potential.
▪ Advise pt. to notify HCP if pain control is not adequate or if severe/persistent side effects occur.
▪ Advise pt. to change positions slowly to minimize orthostatic hypertension.
▪ Encourage pt. to turn, cough & breathe deeply every 2 hrs. to prevent atelectasis.

Resource: Davis’s Drug Guide

PATIENT EDUCATION WORKSHEET

NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION:
Clindamycin hydrochloride 600 mg intravenous Piggyback (IVPB) q8h x3
CLASSIFICATION:
Therapeutic: anti-infectives
PROTOTYPE:
Antibiotics

SAFE DOSE OR DOSE RANGE, SAFE ROUTE

The safe dose & route for adults for most infections is: 300-600 mg every 6-8 hr or 900 mg every 8 hr. 600 mg IVPB is considered to be a safe dose &
route for this pt.
PURPOSE FOR TAKING THIS MEDICATION
▪ Treatment of skin & skin structure infections, respiratory tract infections, septicemia, osteomyelitis, gynecologic infections, intra-abdominal
infections & endocarditis prophylaxis.

PATIENT EDUCATION WHILE TAKING THIS MEDICATION

▪ Instruct pt. to notify HCP immediately if experiencing diarrhea, abdominal cramping, fever or bloody stools occur & not to treat with antidiarrheals
w/o consulting HCP.
▪ Advise pt. to report signs of superinfection (furry overgrowth on the tongue, anal itching or discharge).
▪ Instruct pt. to take medication ATC at evenly spaced times & to finish completely as directed, even if feeling better. Do not double dose.
▪ Inform pt. that bitter or metallic taste occurring with IV administration is not clinically significant.
▪ Instruct pt. to notify HCP if no improvement occurs within a few days.

Resource: Davis’s Drug Guide

PATIENT EDUCATION WORKSHEET

NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION:
Iron polysaccharide 150 mg Oral (PO) q12h
CLASSIFICATION:
Therapeutic: antianemics
Pharmacologic: iron supplements
PROTOTYPE:
Iron Supplements
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
The safe dose & route for adults is 50-100 mg 2x daily of tablets/elixir or 150-300 mg/day of the capsules. 150 mg Oral (PO) q12h is considered to be a
safe route & dose for this pt.
PURPOSE FOR TAKING THIS MEDICATION
▪ Prevention & treatment of iron-deficiency anemia.

PATIENT EDUCATION WHILE TAKING THIS MEDICATION

▪ Explain purpose of iron therapy to pt.
▪ Advise pt. that stools may become dark green or black & that this change is harmless.
▪ Instruct pt. to follow a diet high in iron.

Resource: Davis’s Drug Guide

PATIENT EDUCATION WORKSHEET

NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION:
Hydrochlorothiazide 25 mg Oral (PO) q12h
CLASSIFICATION:
Therapeutic: antihypertensives, diuretics
Pharmacologic: thiazide diuretics
PROTOTYPE:
Diuretic (Thiazide)
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
The safe dose & route for this medication is: 12.5-100 mg/day in 1-2 divided doses (up to 200 mg/day); not to exceed 50 mg/day for hypertension. 25 mg
Oral (PO) q12h is considered to be a safe dose & route for this pt since he has mild hypertension.
PURPOSE FOR TAKING THIS MEDICATION
▪ Management of mild to moderate hypertension.
▪ Treatment of edema associated HF, renal dysfunction & cirrhosis

PATIENT EDUCATION WHILE TAKING THIS MEDICATION

▪ Instruct pt. to monitor weight biweekly & notify HCP of significant changes.
▪ Caution pt. to change positions slowly to minimize orthostatic hypotension.
▪ Advise pt. to continue taking the medication even if feeling better. Medication controls but does not cure hypertension.
▪ Encourage pt. to comply with additional interventions for hypertension (weight reduction, low-sodium diet, regular exercise, smoking cessation,
moderate consumption of alcohol & stress management).
▪ Instruct pt. & family in correct technique for monitoring weekly BP.
▪ Advise pt. to report rash, muscle weakness, cramps, nausea, diarrhea or dizziness to HCP>
▪ Emphasize importance of routine follow-up exams.

Resource: Davis’s Drug Guide

 Clinical
Date: 10/15/20 Student Name: Karina Rodriguez Worksheet Assigned vSim: Jared Griffin
Initials: Diagnosis: HCP: Isolation: IV Type: Critical Labs: Other Services:
Osteoarthritis Contact Precautions Dextrose 5% CBC Test: Discharge Planner
J.G. MRSA Lonny Washington sodium chloride Hb: 11 (low) Social Worker
Hypertension Fall Risk: 0.45% of HCT: 36% (low) Home Health Aide
Age: 63 Morse Fall continuous BMP: Occupational Therapist
Length of Risk Score: Infusion Cl-: 100 (low)
M/F: Stay: 2 Consults: 15 (Low
days Physical Therapy Risk) Location: Bone Scan Consults Needed:
M Accessory Cephalic Vein X-ray Imaging Physical Therapy
Allergies: Dressing clean, dry & CT Scan Social Services
Code Status: Codeine Transfer: Pt. needs intact Rehabilitation (Transitional
Full Code limited assistance to Care Unit)
transfer/ambulate
Fluid/Rate: 60 mL every 1
hr (rate not given on
order)

Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: Pt. has been admitted due to worsening osteoarthritis
resulting in having a total right knee arthroplasty (TKA) performed.

Health History/Comorbities (that relate to this hospitalization): Pt. has a 10-year history of worsening osteoarthritis that has affected his right knee. Pt. was
diagnosed with MRSA 3 yrs ago when having surgery for hammertoe & is currently on contact precautions. Pt. also has a history of mild hypertension. immunizations
are up to date. Pt. is a non-smoker and reports drinking less than 1 drink per week. Pt. reports never exercising.
Shift Goals/ Patient Education Needs:
1. Pt. pain level will be reassessed every 4 hrs. and maintain a pain level of 2 out of 10 for the remainder of ths shift.

2. Pt. will be able to perform active ROM exercises every 2 hrs without needing assistance & be able to flex knee at 90 degrees by remainder of shift.

3. Pt. will remain free of infection by inspecting wound integrity & having a head-to-toe assessment performed every 4 hrs.

4. Pt. vital signs will be monitored and any abnormalities/changes recorded every 4 hrs.

Path to Discharge:
Pt. will be seen by a physical therapist prior to discharge and will be educated on safety, fall risk & use of assistive devices.
Pt. will have home assessed by a home health aide to ensure home is safe and free of fall risks prior to being discharged from hospital.
Pt. & caregiver will be provided with instructions on how to properly apply anti-embolism stockings prior to discharge.
Path to Death or Injury:
Pt. & caregiver will be educated on call lights & have a call light placed at close proximity to pt. bedside to prevent any falls/injury from happening.
Pt. & caregiver will be educated on the importance of repositioning every 2 hrs to prevent pressure injuries.
Pt. & caregiver will be educated on how to properly apply anti-embolism stockings to prevent DVT and promote venous return.
 Clinical
Pt. & caregiver will be educated on how to properly change Worksheet wound dressing on right knee to prevent infection.
 Alerts:
What are you on alert for with this patient? (Signs & Symptoms)
1. High WBC count & Fever indicating infection, such as an abscess formation at wound
site on knee or temperature of 99F or higher.
2. Warmth, swelling or redness of skin on lower extremities indicating edema.
3. Pt. reporting pain level of 5 or higher.
What Assessments will focus on for this patient? (How will I
identify the above signs & symptoms?)
1. Inspection of wound site every 2 hours for abscess formation or any wound drainage.
2. Inspection of lower extremities every 2 hours to assess for edema formation.
3. Pain Assessment will be done every 4 hrs to assess/monitor for changes in pain level.
4. Performing vital signs every 4 hrs & monitoring CBC count to detect abnormal
changes.
List Complications may occur related to dx, procedure, comorbidities:
1. Pt. may develop infection on wound site & result in sepsis if not monitored properly.
2. Pt. may develop DVT in lower extremities related to TKA procedure.
3. Pt. may experience shortness of breath/pulmonary embolism due to silent DVT
formation.
What nursing or medical interventions may prevent the above Alert or complications?
1. RN will perform a respiratory assessment every 2 hrs to monitor for adventitious
breath sounds or abnormal changes in respiratory rate.
2. RN will assess the wound site on pt. knee every 2 hrs & change dressings as needed
to prevent infection.
3. RN will monitor lab diagnostics & vital signs every 4 hrs to assess for abnormal
changes or signs of infection.
4. RN will elevate pt. legs & apply anti-embolism stockings to prevent DVT formation.
Management of Care: What needs to be done for this Patient
Today? 1. Assess & monitor vital signs/lab diagnostics every 4 hrs.
2. Reposition pt. every 2 hrs & elevate lower extremities to prevent DVT formation.
3. Meet w/ social worker to discuss home nurse aide options & assessing home safety.
4. Perform a pain level assessment every 4 hrs. & monitor pain levels.
5. Incentive spirometer will be utilized by pt. 10x every hour to improve respiration.
6. Assess surgical incision using COCA for signs of infection every 2 hrs & change wound
dressing as needed.
Priorities for Managing the Patient’s Care Today
1. Pt. will have circulation assessed on lower extremities and anti-embolism stockings
removed on/off every 2 hrs.
2. Pt. will stay hydrated, offered a low-sodium diet if tolerated and have I&O recorded every
hour.
3. Pt. will have vital signs taken every 4 hours & have lab values monitored for any signs of
infection
4. Pt. will be repositioned in bed every 2 hours and have legs elevated to prevent DVT.
5. Pt. wound site will be monitored & assessed for any signs of infection every 2 hrs.
6. Pt. will use incentive spirometer 10x every hour to improve respiration & be educated on
its use.
What aspects of the patient care can be Delegated and who can do it?
- Taking vital signs periodically & retrieving lab values from the lab for the patient can
be delegated to a UAP & LPN.
- Recording & collecting I&O information can be delegated to a UAP & LPN.
- Assessing the pts. musculoskeletal function & neurological status after surgery can
be delegated to a physical therapist or an occupational therapist.
- Repositioning & elevating lower extremities of the pt. every 2 hrs can be delegated
to a UAP & LPN.
- Toileting & feeding the pt. can be delegated to a UAP & LPN.
- Wound dressing change can be delegated to an LPN.