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fundamental- Vsim Kim Johnson clinical worksheet

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KIM JOHNSON- CLINICAL WORKSHEET KJ 26F DX- T8 SCI LOS- 1 day NKA No falls No critical labs PT needed to see Rehab facility. Status post GSW T8 comorbidity Shift goals and Pt ducations- straight cath and info on that, focus on repositioning in bed Path to DC- success...

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  • November 13, 2022
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  • 2022/2023
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KIM JOHNSON- CLINICAL WORKSHEET

KJ 26F

DX- T8 SCI

LOS- 1 day

NKA

No falls

No critical labs

PT needed to see

Rehab facility. Status post GSW

T8 comorbidity

Shift goals and Pt ducations- straight cath and info on that, focus on repositioning in bed

Path to DC- successfully cath independently (show back) and needs assistance with ADLs

Path to Death/Injury- Sepsis (not cathing properly) and pressure ulcers (skin hygiene and repositioning to
prevent pressure ulcers)



BACK-

Alert- urinary retentions, resp compromise, constipation, dvt, proper nutrition, pressureulcer

Focus- respiratory, skin, GI/GU, PO intake (leads to skin breakdown and PU)

Complications rt to DX- Pressure ulcers, bowel obstructions, resp complications, infections, risk for PE
(lack of movement)

Interventions- straight cath (prevent uti and retn) turn, pulmonary toiley, TCDB, bowel regimen (rectal
stimulation) compression stockings-

Management of Care- Per Orders VS Q8- reg hi fiber, Q8 I&O, straight cath Q4 (bladder scan) meds
reviewed and administered

Priorities- Straight Cath with Education, OOB with TCDB

Delegations- Turning




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