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  • vSim ISBAR Student Activity Worksheet

    vSim ISBAR Student Activity Worksheet

    INTRODUCTION

    Your name, position (RN), unit you are working on

    “Hi my name is Ryann and I’m the RN working on the surgical unit.”

    SITUATION

    Patient’s name, age, specific reason for visit

    “I’m taking care of Sara Lin, 18 year old female DOB 01/04/02 who had an emergency appendectomy 2 days ago. We’ve discontinued IV medications. She will be receiving oral medications and be discharged this afternoon.”

    BACKGROUND

    Patient’s primary diagnosis, date of

    admission, current orders for patient

    “She came to the ED on 04/08/20 experiencing some nausea and vomiting with increased abdominal pain. She was taken to surgery that day and had an open appendectomy for a ruptured appendix. She has been stable since she’s been up here on the unit.

    Orders –

    · Discontinue IC ceftriaxone

    · Discontinue saline lock upon discharge

    Medications –

    · Oxycodone 5 mg PO Q4H PRN for pain

    · Acetaminophen 325 mg PO Q4H PRN for pain

    · Levofloxacin 500 mg PO daily for 7 days

    Activity – up as tolerated

    No heavy lifting, no driving

    May shower, cover incision with dry dressing.

    Discharge after 1500

    Schedule follow up in Dr. Patel’s office in 1 week

    ASSESSMENT

    Current pertinent assessment data using head

    to toe approach, pertinent diagnostic tests, vital

    signs

    Vital Signs –

    BP – 134/82

    O2 – 98%

    Temperature – 99 F

    Pulse – 105 strong, equal bilaterally. S1 and S2 sounds heard. Strong and fast heart rate.

    Radial and Pedal pulses were strong and 98 equal bilaterally.

    Respirations – 20 – equal, labored, clear to auscultate.

    Remind her to use incentive spirometer.

    Bowel sounds – active

    Incision – no signs of redness, swelling, discharge, inflammation. No signs of infection.

    Pain scale – 6/10 after PO pain medication it was a 3 after 30 minutes.

    Skin turgor less than 3 seconds. No signs of dehydration.

    Skin is cool and moist – sweaty.

    Cap refill less than 2 seconds.

    Mucous membranes are clear no signs of tenderness, swelling, or drainage.

    PEARL – pupils are equal and reactive to light

    Neuromuscular assessment – ROM 5/5 all extremities.

    IV in right hand – no signs of redness swelling or infiltration.

    Blood analysis –

    WBC is 15 billion. (3.5-10).

    RECOMMENDATION

    Any orders or recommendations you may

    have for this patient

    My recommendation is if before she leaves can we get an order for something that’ll help with her anxiety? She’s extremely anxious when she gets in too much pain and she’s anxious about the care she needs to do at home.

    Adapted from Wolters Kluwer vSim ISBAR Activity Student Worksheet

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