simulation med surge

Patient Information

• Patient Name: Millie Larson
• Age: 84 years old
• Gender: Female
• Diagnosis: Dehydration and Urinary Tract Infection (UTI)
• Code Status: Full code
• Allergies: No known allergies

Medical History

• Hypertension
• Glaucoma
• Osteoporosis
• Arthritis
• Elevated Cholesterol
• Stress Incontinence
• Medication Compliance: Uncertainty regarding recent medication intake; daughter unable to verify if medications were taken from medication box.

Admission Details

• Admitting Unit: Medical-Surgical (med surg)
• Initial Source of Admission: Emergency Department (ED)
• Reason for ED Visit: Patient was confused and not acting normally during daughter's visit.
• Time of Admission: Patient admitted to med surg after spending the night in the ER before a bed became available about one hour prior to the current observation.

Background Summary

• Millie's daughter, Taylor, visited the patient yesterday evening and reported confusion.
• Patient was brought to the ED where she was evaluated and subsequently admitted.

Vital Signs at 0600

• Heart Rate: 86 bpm
• Blood Pressure: 176/98 mmHg
• Respiratory Rate: 16 breaths per minute
• SpO2 (Oxygen Saturation): 97% on room air
• Temperature: 98°F
• Pain Level: 0 (none reported)

Nursing Actions and Recommendations

• Initial Physical Assessment: To be performed by the day shift nurse.
• CAM (Confusion Assessment Method) Evaluation: Completion of CAM assessment recommended for evaluating cognitive function.
• SPICES Evaluation: To be conducted, focusing on common geriatric syndromes: Sleep disorders, Problems with Eating, Incontinence, Confusion, Evidence of Falls, and Skin Breakdown.

Physician Information

• Doctor in Charge: Dr. Garcia
• Follow-Up: Dr. Garcia will see the patient later in the morning.

Family Communication

• Taylor (patient's daughter) has left to change clothes and will return within one hour but is available by phone if needed.

Time Confirmation

• Current Time: 07:30 AM
• Time of Last Vitals: 06:00 AM