1. Smith Case Scenario Presenting Complaint: have a headache.” “I Gender and age: 22 year old male Case Name: Smith Key Objectives: Perform health history and focused assessment in a primary care setting: (PC learners) All learners Refer to previous primary care SOAP note written Demonstrate on previous clinical exam (3 days prior to this visit) focused history & Complete a focused history and physical exam PE Report findings to facilitator signs of Identify and manage a plan of care clinical Complete appropriate documentation deterioration: Vital Transfer to the ED signs, pertinent Provide complete handoff communication with ED physical exam learner SBAR findings (pale, dry Perform health history and focused assessment in the ED mucus membranes, setting: (ED learners) altered mental Complete a focused history and physical exam status & headache Institute appropriate basic care to patient: pain, photophobia, Monitoring, VS evaluation, oxygen therapy, history vomiting, guarded & physical assessment; IV, obtain blood, IVF); gait) diagnostic evaluation (CT, CXR, CBC, Recognize and Electrolytes, Blood Culture) verbalize need for Report findings to facilitator higher level of care Identify and manage a plan of care Describe nursing Complete appropriate documentation interventions/ Transfer to the ICU management of Provide complete handoff communication with ICU unstable patient: learner using SBAR specifically need Perform problem-focused health assessment in ICU for transfer to setting: (ICU learners) higher level of care Admit to ICU and interventions Complete a focused history and physical exam (hydration, Institute appropriate basic care to patient Report hemodynamic findings to facilitator monitoring, labs, Identify and manage a plan of care imaging) Complete appropriate documentation Communicate Provide SBAR communication to facilitator critical information SBAR during transfer; specifically unstable vital signs and altered mental status Complete comprehensive
1. Smith Case Scenario Presenting Complaint: “I have a headache.” Gender and age: 22 year old male Case Name: Smith Key Objectives: All learners Demonstrate focused history & PE signs of clinical deterioration: Vital signs, pertinent physical exam findings (pale, dry mucus membranes, altered mental status & headache pain, photophobia, vomiting, guarded gait) Recognize and verbalize need for higher level of care Describe nursing interventions/ management of unstable patient: specifically need for transfer to higher level of care and interventions (hydration, hemodynamic monitoring, labs, imaging) Communicate critical information SBAR during transfer; specifically unstable vital signs and altered mental status Complete comprehensive Perform health history and focused assessment in a primary care setting: (PC learners) Refer to previous primary care SOAP note written on previous clinical exam (3 days prior to this visit) Complete a focused history and physical exam Report findings to facilitator Identify and manage a plan of care Complete appropriate documentation Transfer to the ED Provide complete handoff communication with ED learner SBAR Perform health history and focused assessment in the ED setting: (ED learners) Complete a focused history and physical exam Institute appropriate basic care to patient: Monitoring, VS evaluation, oxygen therapy, history & physical assessment; IV, obtain blood, IVF); diagnostic evaluation (CT, CXR, CBC, Electrolytes, Blood Culture) Report findings to facilitator Identify and manage a plan of care Complete appropriate documentation Transfer to the ICU Provide complete handoff communication with ICU learner using SBAR Perform problem-focused health assessment in ICU setting: (ICU learners) Admit to ICU Complete a focused history and physical exam Institute appropriate basic care to patient Report findings to facilitator Identify and manage a plan of care Complete appropriate documentation Provide SBAR communication to facilitator
SIH_2013_01_02_BONNELL_200452_SDC1.docx