Practice Scenarios for 5D: Vital Signs
Practice Scenarios for Flowsheet Charting
Vital Signs, General Assessment & I&O Flowsheets
Launch MICS LastWord Training Pathway
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.
1
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.
2
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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4
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Note: On the floor you only need to document on one pain scale.
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