Part 1: Plan of Care Concept Map (adapted from vSim template)
Simulation Patient Overview
• Client summary: presentation, medical history and
... [Show More] background, physical assessment
findings, medications, diagnostics
• brief summary of pathophysiology and rationale for clinical manifestations
Red is an 80-year-old male who lives alone, 20 miles from the nearest city. The patient has previously
been diagnosed with type 2 diabetes (six months ago) and has recently began taking insulin. The nurse
came to Reds’ house to assess and evaluate a wound that was caused by wearing shoes that were too
tight. The toe was injured about three weeks ago. It is plausible that Red has developed peripheral
neuropathy which is typically caused by diabetes. This causes loss of sensation and numbness to the
extremities. In Reds’ case, he might have not felt in the injury on his toe and that is why he did not
address it immediately. Red also lives alone so there was no was else in the household to bring his
attention to the injured toe.
The Assessment
Anticipated Physical Assessment Findings
• additional focused assessment
• relevant cues (S&S)
• cues indicating need for immediate
concern and rationale
Anticipated Diagnostic Tests
• relevant cues (abnormal findings)
• additional tests to consider
Peripheral neuropathy – numbness and loss of Abnormal Values
sensation in the feet Part A: No diagnostic tests
Right toe wound
Additional tests to consider – monitoring of blood
glucose x 4 times a day.
Plan
Anticipated Care Priorities Anticipated Nursing Interventions
Monitor blood glucose levels and adhere to
medication.
Wound dressing.
Educate patient on: the importance of monitoring
his blood glucose after meals, and adhering to the
sliding scale dosage, daily inspection of feet with
help of mirrors and family, how to apply wound
dressings on his right toe to prevent further
complications, information on diet and nutrition.
Feet inspection.
Great importance must be placed on footcare.
© Wolters Kluwer Health | Lippincott Williams & Wilkins
Diet and nutrition information.
Sleep education. Assess independence in ADLs.
ISBAR Worksheet (adapted from vSim)
ISBAR Student Notes
Introduction
• Your name, position (Nursing student), unit
you are working on
• What is the purpose of this communication?
Hello, my name is Ronit Patel. I am student RN
with a home health agency. I will be giving you a
report on Red Yoder.
Situation
• What is happening at the moment?
• Patient’s name, age, specific reason for
visit/admission
Red Yoder is an 80-year-old male that is being
seen at home for a right toe wound.
Background
• What are the issues that led up to this
situation?
• Patient’s primary diagnosis, date of
admission, current orders
The patient was diagnosed with type two diabetes
six months ago. He has recently began taking
insulin. Red suffered an injury to his toe three
weeks ago. Up till now, he has been wearing tight
shoes which progressively made his injury worse.
No current orders.
Assessment
• What do you believe the pr [Show Less]