vSim ISBAR Student Activity Worksheet
Your name, position (RN), unit you are working on
“Hi my name is Ryann and I’m the RN working on the surgical unit.”
Patient’s name, age, specific reason for visit
“I’m taking care of Sara Lin, 18 year old female DOB 01/04/02 who had an emergency appendectomy 2 days ago. We’ve discontinued IV medications. She will be receiving oral medications and be discharged this afternoon.”
Patient’s primary diagnosis, date of
admission, current orders for patient
“She came to the ED on 04/08/20 experiencing some nausea and vomiting with increased abdominal pain. She was taken to surgery that day and had an open appendectomy for a ruptured appendix. She has been stable since she’s been up here on the unit.
· Discontinue IC ceftriaxone
· Discontinue saline lock upon discharge
· Oxycodone 5 mg PO Q4H PRN for pain
· Acetaminophen 325 mg PO Q4H PRN for pain
· Levofloxacin 500 mg PO daily for 7 days
Activity – up as tolerated
No heavy lifting, no driving
May shower, cover incision with dry dressing.
Discharge after 1500
Schedule follow up in Dr. Patel’s office in 1 week
Current pertinent assessment data using head
to toe approach, pertinent diagnostic tests, vital
Vital Signs –
BP – 134/82
O2 – 98%
Temperature – 99 F
Pulse – 105 strong, equal bilaterally. S1 and S2 sounds heard. Strong and fast heart rate.
Radial and Pedal pulses were strong and 98 equal bilaterally.
Respirations – 20 – equal, labored, clear to auscultate.
Remind her to use incentive spirometer.
Bowel sounds – active
Incision – no signs of redness, swelling, discharge, inflammation. No signs of infection.
Pain scale – 6/10 after PO pain medication it was a 3 after 30 minutes.
Skin turgor less than 3 seconds. No signs of dehydration.
Skin is cool and moist – sweaty.
Cap refill less than 2 seconds.
Mucous membranes are clear no signs of tenderness, swelling, or drainage.
PEARL – pupils are equal and reactive to light
Neuromuscular assessment – ROM 5/5 all extremities.
IV in right hand – no signs of redness swelling or infiltration.
Blood analysis –
WBC is 15 billion. (3.5-10).
Any orders or recommendations you may
have for this patient
My recommendation is if before she leaves can we get an order for something that’ll help with her anxiety? She’s extremely anxious when she gets in too much pain and she’s anxious about the care she needs to do at home.
Adapted from Wolters Kluwer vSim ISBAR Activity Student Worksheet
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