User's Manual

Practice with facility’s software

Logging on to your facility test system or with practice patients, enter the following data using the pen as

your input device:

Shift Assessment:

• Blood pressure (BP) 164/80

• Pulse 92

• Respiratory rate 24

• Temp 38.2 C / 100.8 F

• Pulse saturation 89%

Respiratory

: Crackles in LLQ posterior, decreased breath sounds in all fields. No pain on inspiration. Dry

cough. Uses incentive spirometer every hour to 900ml. You place the patient on Oxygen 2L via nasal

cannula per order.

Cardiac

: denies chest pain, normal sinus rhythm, radial pulses present and equal bilaterally

: Bowel sounds absent, states has not had a BM in 48 hrs, tender to palpation in LLQ

Skin

: cool, dry, slightly pale, has a left flank incision with clean dry dressing in place, wound drain has

scant amount of bloody drainage in it

: 20 gauge in his right forearm D5 ½ NS at 125cc/hour, site is slightly red, puffy, and tender to

palpation. You remove IV and restart with 20 gauge in left forearm

Pain

: rating pain at 7/10 – aching pain in left flank, increases with movement

Activity

: up to bathroom without assistance. Walking slowly, stooped over and holding left flank

– 300 cc cloudy yellow urine in urinal, slightly foul odor – sample sent for UA per protocol

Teaching activity

: signs and symptoms of potential urinary tract infection – demonstrated understand by

repeating signs and symptoms and correctly identifying which are currently present

Psycho-social

: Spouse and children at bedside, chaplain scheduled to visit today

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