Practice Scenarios for 5D: Vital Signs



Practice Scenarios for Flowsheet Charting

Vital Signs, General Assessment & I&O Flowsheets

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Vital Signs Flowsheet

1. You have taken vital signs on your patient. Add a new column and document on the following rows for the current date/time.

|Temperature (C) |37.5 |

|Pulse Rate (beats/mn) |88 |

|Systolic BP |130 |

|Diastolic BP |70 |

|Respirations (min) |24 |

|Height (cm) |175 |

|WeightAdmission (kg) |63 |

2. You entered the incorrect temperature. Update this row with the correct information.

|Temperature (C) |37.9 |

3. Add a new column and chart on the following rows.

|Temperature (C) | 37.2 |

|Pulse Rate (beats/mn) | 68 |

|Systolic BP | 110 |

|Diastolic BP | 70 |

|Position/Cuff |Right Arm Standing |

|Respirations (min) | 16 |

|SpO2 (%) | 98 |

|Weight (kg) | 65 |

|Wt Chg Admit |Will auto calculate if this row selected to chart on |

4. You entered an incorrect daily weight. Select weight and weight Chng cells and record the correct daily weight.

|Weight (kg) |update to be 67 kg Ok to accept calculation |

|Wt Chg Admit | |

5. Review the information you have entered for these scenarios in the Patient Data Views – select Vitals Intake/Output.

6. Display information in 1-hour increments. Select Column from the menu bar and choose One Hour.

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General Assessments Flowsheet

1. You’ve completed a multi-system assessment on your patient. Add a new column and document the following.

|Skin Assessment |Not Met |

|PressurePoint Checks |NotMet |

|Tissue Perf Assess |Not Met |

|Respiratory Assess |Not Met |

|Sens Percept Assess |Met |

|Activ/Mobil Assess |Not Met |

|Anxiety/Cope Assess |Not Met |

|Safety Assessment |Met |

|Health/Home Assess |Not Met |

|Nutri/Fluid Assess |Met |

|Elim/Output Assess |Met |

Chart the following for the above date & time in the Pain section. Hint: update existing column.

|Pain #1 Location |Chest |

|Numeric Pain Scale#1 |2 |

|Faces Pain Scale #1 |6 |

|Pain #1 Descriptors |Burning |

|Pain #1 Duration |Modifier: Minutes |

| |Result: 10 |

|Pain #1 Frequency |Intermittent |

| |Comment: Type “on inhalation” |

|Pain#1 Pharm Interv |Medicated |

Make the following changes.

|Faces Pain Scale |was charted in error delete this finding |

|Pain #1 Descriptors |change from “Burning” to “Sharp” |

2. Highlight (select) the cells that have been changed for Faces Pain Scale #1 and Pain #1 Descriptors and select the “Display Details” button. Note the audit trail.

|Sensory Perception |4 – No impairment |

|Skin Moisture |3 – Occasionally moist |

|Patient Activity |1 – Bedfast |

|Patient Mobility |2 – Very Limited |

|Patient Nutrition |2 – Probably inadequate |

|Friction/Shear |1 – Problem |

In the Skin General Section, chart on the Braden Skin Score rows.

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In the Intravas Device section, document the following:

|IV Rate (ml/hr) |100 ml/hr, modify the result with D5 0.9NS + 20KCL/L |

|Med Inf Dose |500, modify the result with Heparin units/hr |

|Int Dev#1 Insert Date |Today’s date (0D) |

|Int Dev #1 Location |Hand Right |

|Int Dev #1 Type |Peripheral, no symptoms on Phlebitis scale |

|Int Dev #1 Site Cond |Within Normal Limits |

|Int Dev #1 Status |Patent x1 |

|Int Dev #1 Drsg Type |Adhesive Strip |

|Int Dev #1 Drsg Stat |Dry/Intact |

3. Highlight (select) the column of data and click the “Change Time” button. Change the time (for all flowsheet sections) to the previous hour.

4. Add a new column and back chart the time two hours prior to your initial assessment.

(Hint: in Activity/Home Section)

|Patient Seen By |Resident |

|Physician Rounds |Primary |

|Service Notified |Pain Sx |

5. Chart a new pain assessment using the current date/time. (Notice how your previous Results are templating forward. You can accept or change the previously charted result.)

|Pain #1 Location |Chest |

|Numeric Pain Scale#1 |8 |

|Pain #1 Descriptors |Sharp |

|Pain #1 Duration |1 hour (Use Modifier “hours”) |

|Pain#1 Pharm Interv |Medicated |

6. Review your charting in the Viewer using the following options:

• Go to Patient Data Views tab > Nurse Notes and Assessments > use Filter to select Neurologic/Pain > click OK.

• Go to Patient Data Views tab > Nurse Notes and Assessments > use Filter to select Skin > click OK.

• Go to Patient Data Views tab > Nurse Notes and Assessments > use Filter to select IV/Incisions/Drains > click OK.

• Use the My Favorite that you previously set for the General Assessment flowsheet view.

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Note: On the floor you only need to document on one pain scale.

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