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.