ER Simulation assessment assignment
Assignment Post Simulation Game Emergency Room Assessment
- Roman was assessed by the nurse. She collected both objective and subjective data. Please explain in your own words what subjective and objective data is and give an explain from Roman’s assessment for each.
Subjective – Data based on what the patient says or how the patient feels
Pain- 5/10, been vomiting at home for the last few days, pain in abdominal area when touching
Objective – Data based on observation made by a nurse or healthcare worker
Slight abdominal distension, confused, HR – 80, systolic – 130, Resp – 20, Temp 37.4, O2 – 94% RA, systolic rate is dropping and pulse increasing, faint bowel sounds
- After observing Abel’s assessment done by the nurse, she collected both objective and subjective data. Divide the data collected by the nurse into 2 columns subjective (remember to use quotation marks) and objective data. (You may have to replay this section of the game and make notes of Abel’s assessment if you haven’t already)
| Subjective | Objective |
| 2 hours prior took 2 puffs of Ventolin | difficulty Breathing |
| Breathing worse than when he came in | Inspiratory and expiratory wheezes |
| Peak flow: 190 Expected: 390 | |
| Decreased air entry bilateral to the bases | |
| O2 = 93% RA | |
| RESP = 26 | |
- After observing Charlotte’s Assessment and the collection of her subjective and objective data, divide it into 2 columns subjective and objective data. (You may have to replay this section of the game and make notes of Charlotte’s assessment.)
| Subjective | Objective |
| Pain level
Still: 3/10 Move: 6/10 |
Alert and responsive |
| Can feel hand on both feet | Left leg shorter than right and externally rotated |
| Feels pain on left hip when wiggling left foot | Has bruises in left and right harm |
| Has fallen previously and has some past bruises as well as new ones | left foot is colder and has weaker pulse than right foot |
| Always bumping into things | Can wiggle both feet |
| Vitals are stable | |
Gordon’s Functional Health Patterns Assessment Tool
Student Name _Uvbi Osatohangbon___ Date(s) cared for __Nov. 16/2022____________________
Client’s Initials __QO__Age __15____Dr. ____________Co-assigned nurse ________________
Diagnosis _________________________________________________________________
History ___________________________________________________________________
| Health Pattern | Report | Shift Assessment |
| Health Perception –
Health Management:
Ø Allergies Ø Risk for falls Ø Gait/coordination Ø Personal Care Ø Skin condition: wounds/dressing Ø Side rails/call bell
|
– No allergies – Low risk of fall related to good balance and age – Risk of fall may increase due to winter weather – Good gait and coordination, no problems were noted – No wounds or dressing, skin is in good condition |
|
| Nutritional – Metabolic:
Ø Diet/fluids/appetite Ø Risk for choking Ø Integrity of mm Ø IV solution/rate/site
|
– Craving a lot of sweet things and vanilla
Coffee – Diet has been mostly consisting of carbohydrates and grains – Normally doesn’t have trouble swallowing Therefore, is at low risk for choking. Risk increases when eating to fast or not chewing enough |
|
| Elimination:
Bowels Ø Last BM: colour/consistency Ø Bowel Sounds/continence Ø Laxative use/suppositories Urinary Ø Pattern/freq/amount/colour/clarity Ø Continence Ø Attends/catheter
|
– Last BM: color – brown, consistency – hard/solid – No laxative or suppositories – Continence – Bowel sound present in all 4 quadrants – Urinary continence – Urinary – an avg of 3 times/day – Recently Urine has been a lighter yellow |
|
| Activity – Exercise
Ø TPR/B/P/SpO2 Ø Peripheral pulses/CMS Ø Skin Colour Ø Air entry/adventitious sounds Ø Smoker? Ø Level of activity Ø Assistive Devices Ø Assist with transfers |
– Non-Smoker
– Normal skin color – Walk typically every morning Mon-Fri – No assistive devices or assist with transfer Before exercise – Resp: 20 – HR: 78 After exercise – Resp: 30 – HR: 82 |
| Sleep – Rest:
Ø Sleep Time Ø Rest Patterns Ø Comfort Ø Pain/VAS
|
– Sleep time 7h/day
– No discomfort – Pain: 0 |
|
| Cognitive – Perception:
Ø Oriented x 3 Ø Cognitive status Ø Visual/hearing aids
|
– Alert and oriented to person, place,
time and situation – Uses prescription glasses |
|
| Self Perception – Self concept:
Ø Mood Ø Belief system Ø Understanding of illness & treatments Ø Decision making capacity
|
– Mood – stressed and unmotivated
but does not act upon it and still keeps on pushing through – Is able to make decisions for herself |
|
| Role Relationship:
Ø Support systems (family/friends) Ø Ability to communicate Ø Visitors Ø Social activities
|
– Goes to Family for support
– Can communicate – Social activities: Social justice club, and was previously involved in rugby sport |
|
| Sexuality – Reproductive:
Ø Behavioural issues Ø Expresses/responds to affection
|
– No behavioral issues found
– Expresses and responds to affection towards close friends and sometimes family |
|
| Value – belief:
Ø Personal goals Ø Expression of contentment vs. unfinished business
|
– Goals: keep good grades at school
and a good average, learn more piano – Contentment: 4/10 due to test related stress and unsatisfaction towards existent |
|
| Coping – Stress Tolerance
Ø Stressors Ø Coping methods Ø Recent trauma/surgery/loss
|
– Stressors: upcoming test, job hunting,
Learning piano – No coping methods
|
Other significant data: Patient says she feels like she need help dealing with current stressors in her life
Gordon’s Assessment Tool 2011