Pre-Simulation Plan of Care Student Name___Shabanabanu Malek_____ Date _11/2/2021__ Patient initials _C.J. Patient Age: 68 year Admitting Diagnosis: ____CHF Tests or procedures and analysis of lab values pertinent to admitting diagnosis, include and explain abnormal results: _CBC RBC: 4.17 WBC: 7000 Platelet: 320000 Hgb: 11 Hct: 34.4 S. Creat: 0.7 Albumin: 3.7 Focused Assessment Indicated for the patient: (among those listed below: choose ONE): Include subjective and objection data Cardiovascular: C/o chest pain 7 on pain scale 0 to 10. There was S1 and S2 sound. There was Skin cool, moist. There was gallop. S3 and S4 sound was heard. Capillary refill time 3 second. Psychosocial/ Emotional Respiratory: No complaints of any respiratory distress. No cough. No dyspnaoea. Normal lung sound. Safety: Patient ID was on. Fall risk assessment done. Side rail was up. Call bell and all safety measyre was within reach. GI: Patient had little discomfort in abdomen. Patient c/o of indigestion feeling in epigastric region. No nausea and vomit. Bowel sound normal in all four quadrant. Patient/Family educational needs: educate the paient importance of ambulation. Educate the patient regarding fluid restriction. Educate the patient to sit in high fowler position to decrease venus return. And expansion of thorax region so patient can Patent alert and orient X3 Patient was restless and anxious. easily breath. GU: no bladder distension. Tympany heard over hypogastic region. No any tenderness\. No u=rinary complaints. Musculoskeletal: no bruishing in any extrimities. No any pain or stiffness patient move her extrimities agains resistance. There was muscle streanth 5/5.