Geriatric Nursing Simulation Notes: Edward Carter

Date: April 19, 2026 Setting: Hospital (ED → Medical Floor) Simulation App: Shadow Health (Elsevier) Course: D442 Basic Nursing Skills — March 2026

Simulation Checklist

Subjective Data Collection

• Interview patient — chief complaint, HPI, PMH, social history, family history, review of systems
• OLDCARTS pain assessment
• ADL / IADL status (bathing, dressing, toileting, transferring, continence, feeding/eating)
• Frailty assessment
• Fall risk history (falls in past 12 months, fear of falling)
• Elder abuse screening
• Other geriatric syndromes (incontinence, cognition, nutrition, sleep, skin)
• Medication reconciliation — full home medication list including OTCs and supplements
• Identify Beers Criteria PIMs in medication regimen
• Evaluate polypharmacy risk
• Review PHQ-2 results in EHR and ask appropriate follow-up questions

Education & Empathy

• Educate on discovered medication issues
• Educate on treatment adherence strategies
• Address areas of low health literacy
• Provide information on available healthcare resources
• Use empathy at appropriate moments during the interview

Objective Data Collection

• Hand hygiene performed
• Patient identity verified — Edward Carter, ID# 1207126; wristbands checked ✅ all correct
• Problem-focused physical assessment — musculoskeletal and regional systems
• Assess for geriatric syndrome evidence and risk (falls, pressure injury)
• Administer cognitive impairment / dementia screening (Mini-Cog or equivalent)
• Gait and balance assessment
• Fall risk assessment (objective)
• Infection prevention — hand hygiene and PPE as appropriate

Care Plan

• Identify most appropriate nursing diagnosis with supporting evidence
• Select a measurable short-term healthcare goal
• Plan interventions and data collections to achieve the goal
• Discuss care plan with patient
• Evaluate results and determine how fully the goal was achieved

Team Communication (SBAR Hand-Off)

• Situation — what is happening with Mr. Carter right now
• Background — relevant history and context
• Assessment — your clinical findings and interpretation
• Recommendation — what you are requesting from Preceptor Diana

Self-Reflection

• Complete reflection prompts provided in the simulation

Patient Overview

• Age / Sex / Ethnicity: 68-year-old Black man (DOB 01/01/1958)
• MR#: 1207126 | Physician: Dr. Henry Evans
• Chief Concern: Severe osteoarthritis pain — came to ED at 8 AM; admitted to floor at 11 AM
• Admitting Diagnosis: Progressive osteoarthritis, Rule out syncope ⚠️, Recent Fall ⚠️
• Secondary Diagnoses: HTN, Chronic Afib, CKD Stage 2
• Code Status: Full
• Condition: Stable
• Diet Order: Heart Health/Cardiac diet, Na <2 g/day ⚠️
• Activity Order: BRP with assist ⚠️
• Consults: Physical Therapy, Occupational Therapy
• Primary Diagnoses (PMH): [ ]
• Cognitive Baseline: [ ]
• Functional Status (ADLs/IADLs): [ ]
• Living Situation / Support: [ ]
• Medications (home): [ ]
• Allergies: [ ]

Social Context Note

Black patients face documented disparities in osteoarthritis care — less likely to receive physical therapy, opioids, or surgical referrals. Pain is to be assessed and treated based on the patient’s subjective report. No assumptions based on race.

Phase 1 — Therapeutic Introduction

Patient Presentation (Student Report)

• Alert, communicative, in pain
• Chief complaint volunteered immediately: hip and knee pain — “hurting me terribly”
• Reports: “Couldn’t get out of bed this morning without falling down”
• Emotional state: distressed — “Things are not going well for me”

Communication Approach (Student Report)

• Student introduced self by name and role ✅
• Asked open-ended opener ✅
• Empathy statement used: “I’m sorry you’re not feeling well” — credited ✅

Instructor Coaching

• ⚠️ Empathy opportunity immediately present — “Things are not going well for me” must be addressed in Empathize tab before asking 3 more questions or credit is lost
• Fall this morning during transfer from bed — needs full follow-up: Was he dizzy/lightheaded before falling? Did he lose consciousness? Was anyone with him? Did he injure himself? (Syncope vs. mechanical fall distinction is critical given Afib history)
• Shadow Health tip: Use Empathize tab after any emotional statement — do NOT continue questioning without acknowledging first

CJMM: Recognize Cues

• Pain: bilateral hips and knees, severe enough to cause a fall during a bed transfer
• Fall this morning → correlates with admitting diagnosis “recent fall, rule out syncope”
• Emotional distress → screen for depression (PHQ-2 already in EHR)

Phase 2 — Health History

History Collected

Missed History Elements

• Cynthia and Randi relationship/living situation — still needed
• Advance directives / healthcare proxy
• Transportation and other IADLs (shopping, finances)
• Fear of falling
• Assistive device use at home

CJMM: Recognize Cues / Analyze Cues

Recognize Cues:

• Acute-on-chronic bilateral hip/knee OA pain → fall → back injury
• Syncope ruled out: no dizziness, no palpitations pre-fall
• First fall ever — mechanical, pain-related during bed transfer
• Abnormal gait >12 sec, reduced ROM, hip/knee weakness
• Lower back redness (injury from bed frame)
• Bilateral hip edema, bilateral knee valgus deformity + swelling + crepitus + effusion
• Cognitive screen: oriented x4, 3-word recall intact
• Appetite decreased; energy declining in afternoons
• NSAID (naproxen) contraindicated — CKD2 + anticoagulation

Analyze Cues:

• OA progression → functional decline → fall risk → injury
• CKD2 + naproxen = nephrotoxicity risk requiring immediate medication reconciliation
• Bilateral knee changes (valgus, effusion, crepitus) confirm advanced OA
• Back redness from fall → assess for vertebral injury, skin breakdown
• Gait impairment + weakness → high fall risk → PT/OT consults appropriate
• Fatigue pattern (afternoons) → anemia of chronic disease, CKD-related fatigue, or medication effect (verapamil)

Labs

CBC (Today)

CBC Interpretation

• No infection signal — WBC high-normal but no bandemia, no left shift
• Mild anemia pattern — Hgb 13.0 is below the male reference range (13.5–17.5); low-normal RBC and MCHC suggest possible anemia of chronic disease (ACD) related to CKD and chronic inflammation from OA
• Platelets 405 — upper normal; important context given apixaban + naproxen combination (bleed risk)
• CMP, UA, Uric Acid, Phosphorus results pending — will clarify renal function (CKD2 severity) and rule out gout

CMP (Today)

CMP Interpretation

• CKD Stage 2 confirmed: GFR 62, Creatinine 2.1, BUN 30 — all consistent; no metabolic acidosis yet (CO2 28 normal)
• Naproxen ABSOLUTELY contraindicated: GFR 62 + Cr 2.1 — NSAIDs reduce renal perfusion, accelerate CKD progression; this is the primary education topic for Mr. Carter
• Morphine risk reinforced: CKD → accumulation of morphine-6-glucuronide (active metabolite) → excess sedation/respiratory depression risk; monitor closely
• Apixaban dose review: Reduced dose (2.5 mg) requires ≥2 of 3 criteria: age ≥80 (❌ he is 68), weight ≤60 kg (unknown — obtain weight), Cr ≥1.5 (✅ Cr 2.1). Needs 2/3; currently only 1 confirmed — obtain weight to verify
• Electrolytes normal: K 3.8 reassuring given HCTZ use; continue monitoring
• Liver function normal: No hepatic impairment — good for medication metabolism
• Glucose 82: No diabetes based on today’s fasting glucose
• Albumin 5.0: Good nutritional status — contradicts protein malnutrition concern

Objective Findings

Infection Prevention (PPE/Hand Hygiene)

• Hand hygiene performed ✅
• IV bag verified: 0.9% NaCl 1000 mL @ 100 mL/hr, prepared 0815, patient ID confirmed ✅
• IV pump verified: infusing at ordered rate 100 mL/hr, 250 mL VTBD ✅
• IV site inspected: no erythema, no infiltration, dressing dry and intact ✅

CJMM: Analyze Cues

[ ]

Phase 4 — Geriatric Syndrome Screening (SPICES)

Geriatric 5Ms

CJMM: Prioritize Hypotheses

[ ]

Phase 5 — Medication Review (Beers Criteria®)

Medication List

PIMs Identified

1. Naproxen (NSAID) — Triple threat:
   • CKD2: NSAIDs are nephrotoxic; reduces renal perfusion → worsens kidney function
   • Afib + Apixaban: NSAID + anticoagulant = HIGH GI bleed risk
   • HTN: NSAIDs blunt antihypertensive effect; cause fluid retention
2. Verapamil — Beers: potentially inappropriate if heart failure present; also inhibits P-gp → increases apixaban plasma levels → bleeding risk
3. Morphine — Beers: use caution; older adults have increased opioid sensitivity; CKD causes accumulation of active metabolite (morphine-6-glucuronide) → sedation/respiratory depression risk; fall risk
4. HCTZ — Risk of hyponatremia, hypokalemia, orthostatic hypotension in older adults

Drug–Drug Interactions

• Naproxen + Apixaban — HIGH: significantly elevated GI and systemic bleeding risk
• Verapamil + Apixaban — MODERATE-HIGH: verapamil (P-gp inhibitor) increases apixaban exposure → bleeding risk
• Naproxen + Losartan/HCTZ — NSAIDs blunt ARB and diuretic antihypertensive effect; increase nephrotoxicity risk in CKD

Additional Lab Flags

• Uric acid ordered — Team ruling out gout as contributor to joint pain (gout vs OA)
• CBC, CMP, UA — Baseline; CMP will show renal function (confirms CKD2 severity)
• 12-lead EKG — For Afib history; rule out arrhythmia contributing to syncope/fall

CJMM: Generate Solutions

• Naproxen should be flagged for provider review — contraindicated with CKD + anticoagulation
• Monitor apixaban dosing (verify BID vs daily — possible transcription concern)
• Morphine: assess pain response, monitor sedation level, respiratory rate, fall precautions before/after administration

Nursing Admitting Note (Drafted)

Chief Complaint (Documented)

“Pt. awoke this AM c/o severe bilateral hip and knee pain r/t osteoarthritis. States, ‘my joints gave out’ while attempting to stand from bed. Pt. fell with impact to lower back. Denies LOC, dizziness, syncope. Analgesics provided, for which pt. states pain at 1/10, an improvement from 9/10 earlier in morning.”

History of Present Illness (Documented)

“Pain r/t osteoarthritis reported worsening over past month with severe acute exacerbation this AM leading to fall and trauma to lower back. Pain described as occasionally ‘grating.’ Pt. reports pain worsens with movement and wt. bearing; relieved with rest, warm compresses, knee exercises and elastic knee supports. Pt. took Naproxen 0500 before visit to ED. Pt. denies LOC, dizziness, syncope, N/V. Pt. verbalized concerns of progressive decline in function and mobility.”

Instructor Feedback:

• ✅ Acute-on-chronic pain progression clearly documented
• ✅ OLDCARTS elements covered: character (grating), aggravating (movement, weight bearing), relieving factors, treatment tried (naproxen)
• ✅ Syncope/LOC explicitly ruled out — directly addresses admitting order
• ✅ Patient’s concern about functional decline documented — important psychosocial element
• ✅ Naproxen home dose with time documented — supports medication reconciliation
• ⚠️ Add pain severity: “Pain rated 9/10 at worst this AM, currently 1/10 following morphine 4 mg IV.” — severity is a scored OLDCARTS element
• ⚠️ Add location specifics: “Bilateral hips and knees; no radiation.” — radiation was directly asked and answered
• ⚠️ Add fall mechanism with back finding: “Pt. fell during bed transfer; visible erythema noted to lower back on inspection.”

Allergies (Documented)

“Pt. denies allergies and states NKDA.”

Instructor Feedback:

• ✅ Correct, concise, complete — no changes needed

Past Medical History (Documented)

“Osteoarthritis dx 2 years ago; HTN dx 13 years ago; atrial fibrillation dx. 7 years ago. CKD-2 dx. 6 years ago. Pt. denies further ailments.”

Instructor Feedback:

• ✅ All four diagnoses documented with duration — matches chart exactly
• ✅ Patient denial of additional conditions documented
• ⚠️ Add surgical history: “No prior surgeries. History of kidney stone procedure (non-surgical).”
• ⚠️ Consider adding condition status: “All conditions currently managed medically per patient.” — adds clinical context

Past Surgical History (Documented)

“No prior surgeries except for procedure r/t kidney stone 3 years ago.”

Instructor Feedback:

• ✅ Correct — no prior surgeries on record
• ✅ Distinguishing “procedure” from “surgery” shows clinical precision (likely ureteroscopy or lithotripsy — neither requires operative consent classification as major surgery)
• ⚠️ Minor: time frame (“3 years ago”) is patient-reported — consider: “History of kidney stone procedure approximately 3 years ago per patient report.”
• ⚠️ Strengthen documentation: “No prior surgeries. History of kidney stone procedure (non-surgical) approximately 3 years ago per patient report. No surgical implants, hardware, or complications noted.”

Medication History (Documented)

“Pt. reports full adherence to home medications: Apixaban 2.5mg PO q daily r/t atrial fibrillation; verapamil 80mg PO TID r/t HTN; HCTZ/losartan 100/25mg PO daily r/t HTN; triamcinolone acetonide intra-articular injection PRN r/t osteoarthritic pain. Naproxen 220mg PO BID PRN r/t pain. Naproxen on hold r/t CKD-2 and Beers Criteria geriatric. Patient states NKDA. Pt in ED received morphine 4mg IV 0925 r/t acute pain and currently IV N/S 0.9% 1000mL peripheral IV to L AC initiated 0830.”

Instructor Feedback:

• ✅ Comprehensive — all home medications listed with indication, route, and frequency
• ✅ Documenting naproxen on hold with Beers rationale is excellent clinical judgment — this is a scored safety item
• ✅ ED and inpatient medications included — morphine administration time and current IV documented
• ✅ NKDA documented — allergy reconciliation complete
• ⚠️ Typo: “PO q daily” — “q daily” is redundant; use “PO daily”
• ⚠️ Verapamil indication: patient’s primary driver here is rate control for Afib, not HTN — consider: “verapamil 80mg PO TID r/t Afib rate control/HTN”
• ⚠️ Beers Criteria phrasing is informal — use: “held per Beers Criteria® for potentially inappropriate medication use in older adults (CKD-2 + anticoagulation + HTN risk)”
• ⚠️ Triamcinolone acetonide: document frequency and last dose date — “intra-articular injection, frequency and last dose not reported by patient”

Orientation & Cognitive Status (Documented)

“Pt. A&Ox4. Speech clear, appropriate and coherent. 3-word recall intact (apple, penny, table). Mini-Cog negative for cognitive impairment. No signs of acute delirium.”

Instructor Feedback:

• ✅ A&Ox4 documented correctly (person, place, time, situation — all confirmed)
• ✅ Speech quality noted — relevant for communication and delirium baseline
• ✅ Mini-Cog result included — this is a scored clinical item
• ✅ Delirium baseline established — appropriate given opioid administration
• ⚠️ Add clock draw result if completed: “Clock draw intact/not completed”
• ⚠️ Syncope and LOC explicitly ruled out — directly addresses admitting “rule out syncope” order

Family History (Documented)

“Pt. denies family history of OA. Pt. reports family Hx of HTN, AFib, CKD, DM, CAD, stroke, and cancer. Pt. married for ‘many years’ and has adult daughter.”

Instructor Feedback:

• ✅ OA family history denial documented
• ✅ Cardiovascular/metabolic family burden identified — supports risk contextualization for HTN, Afib, CKD
• ⚠️ Marital status and daughter belong in Social History, not Family History — move those details
• ⚠️ Strengthen specificity: from chart, cancer history includes maternal grandmother (pancreatic), maternal grandfather (colon), mother (breast) — document per family member when known
• ⚠️ Revised example: “Both parents with history of HTN per patient. Family history significant for Afib, CKD, DM type 2, CAD, CVA/stroke, and cancer (maternal line: pancreatic and breast; paternal line: colon). Denies family history of OA.”

Social History (Documented)

“Pt. lives at home with wife and has non-resident adult daughter who provides additional support. Pt. reports good relationships and social engagement. Pt. denies tobacco use. Occasional alcohol use and denies illicit substance abuse.”

Instructor Feedback:

• ✅ Living situation clearly documented (home with wife; non-resident adult daughter as support)
• ✅ Tobacco use denial documented
• ✅ Alcohol acknowledged and illicit substance use denied
• ✅ Social support network identified — relevant to discharge planning
• ⚠️ “Occasional alcohol use” — strengthen with patient’s own rationale: “Pt. reports rare alcohol intake, self-limiting secondary to CKD awareness.”
• ⚠️ Add: “Advance directives and code status not yet assessed — to be completed during admission.”
• ⚠️ Consider adding: occupation/retirement status and activity level (patient reported enjoying activities that are now limited by OA)

Review of Relevant Systems (Documented)

“GEN: Pt reports fatigue and generalized weakness r/t acute pain and recent fall. HEENT: Denies headaches, vision changes, or hearing loss. RESP: Denies SOB, cough, dyspnea. CV: Denies chest pain, palpitations, lower extremity edema. GI: Denies N/V/D; denies constipation. GU: Denies dysuria, urgency, frequency. NEURO: Denies numbness, tingling, tremor, dizziness. A&Ox4. Denies confusion, cognitive changes. MUSC/SKEL: Bilateral hip and knee pain C/C, 9/10 at admission to ED with improvement to 1/10 after morphine. Pain chronic r/t osteoarthritis with acute worsening beginning this month. Bilateral hip and knee stiffness, reduced ROM. Functional limitations observed with ambulation and transfers. SKIN: Denies rash, lesions, itching. Lower back redness and bruising r/t fall this AM. PSYCH: Denies depression, anxiety. PHQ-2 negative at 0/6. Affect appropriate and mood euthymic.”

Instructor Feedback:

• ✅ Comprehensive multi-system ROS — strong documentation
• ✅ Pain trajectory (9/10 → 1/10 post-morphine) explicitly documented
• ✅ Syncope/dizziness/LOC ruled out in NEURO — directly addresses “rule out syncope” order
• ✅ Skin finding (lower back erythema/bruising) documented with mechanism
• ✅ PHQ-2 result documented in PSYCH — correct placement
• ⚠️ Multiple spelling errors in your draft — corrected above: “palpitations” (not “palpitaions”), “dysuria” (not “dysurea”), “cognitive” (not “congnitive”), “bilateral” (not “bilaterla”), “mood euthymic” (not “modd”) — always proofread before submitting
• ⚠️ GU: consider adding urinary continence status given CKD and age — relevant geriatric assessment item

Functional Status & Geriatric Syndromes (Documented)

“Pt. independent in grooming, dressing, toileting, and feeding (ADLs intact). High risk for falls. PHQ-2 depression screen 0/6 — negative for depression. Gait antalgic; ambulates with standby assist. Hendrich II Fall Risk score elevated per assessment.”

Instructor Feedback:

• ✅ ADL independence documented — important baseline for care planning
• ✅ High fall risk identified and stated — CRITICAL given reason for admission
• ✅ PHQ-2 result correctly documented
• ✅ Antalgic gait and assisted ambulation matches your physical exam findings
• ⚠️ Document the actual fall risk tool used and score (Hendrich II or Morse — whichever the sim uses) with the numeric score
• ⚠️ Mini-Cog result should also appear here: “3-word recall intact; Mini-Cog negative for cognitive impairment.”
• ⚠️ IADLs not yet documented — patient expressed concerns about shopping and driving; note if independently managing
• ⚠️ SPICES finding: Sleep not assessed — ask if not yet asked

Objective Data — Physical Assessment (Documented)

Vital Signs

IV Assessment

Head, Face & Eyes

• Skull and facial features: symmetric; no abnormal findings
• Pupils: PERRL — no trauma-related neurologic concern
• Mouth: not fully documented in submission (see note below)

Objective Data — Physical Assessment (Full Assessment Record)

Legend: ✅ = selected finding | ⬜ = option not selected | ⚠️ = incomplete/not assessed

✅ Assessed Vitals

Temperature

• ✅ Normothermic
• ⬜ Hyperthermic
• ⬜ Hypothermic

Blood Pressure

• ⬜ Normotensive
• ✅ Hypertensive
• ⬜ Hypotensive

Heart Rate

• ⬜ No abnormal findings
• ⬜ Tachycardic
• ✅ Bradycardic (consistent with verapamil — calcium channel blocker for Afib rate control)

Respiratory Rate

• ✅ No abnormal findings
• ⬜ Tachypnea
• ⬜ Bradypnea

O2 Saturation

• ✅ No abnormal findings
• ⬜ Hypoxemia

✅ Assessed IV Bag

Appropriate fluid

• ✅ Bag is normal saline (matches order)
• ⬜ Bag is not normal saline
• ⬜ Bag is not labeled

Appropriate label

• ✅ Name and dosage are correct
• ⬜ Name is incorrect
• ⬜ Dosage is incorrect
• ⬜ Infuse rate is incorrect
• ⬜ Bag is not labeled

Fluid appearance

• ✅ No visible abnormal appearance
• ⬜ Cloudy
• ⬜ Inappropriate color
• ⬜ Crystallization

✅ Assessed IV Pump

Observations

• ✅ IV pump is infusing IV fluid at the ordered rate
• ⬜ IV pump is infusing IV fluid at a slower than the ordered rate
• ⬜ IV pump is infusing IV fluid at a faster than the ordered rate

✅ Inspected IV Site

Insertion site

• ✅ No visible abnormal signs
• ⬜ Erythema
• ⬜ Infiltration

Dressing

• ✅ Dry and intact
• ⬜ Moist dressing

⚠️ Inspected Head and Face (section not v-marked — assessment may be incomplete)

Skull symmetry

• ✅ Symmetric
• ⬜ Asymmetric

Facial feature symmetry

• ✅ Symmetric
• ⬜ Asymmetric

Appearance

• ✅ No visible abnormal findings
• ⬜ Rash
• ⬜ Papules, pustules, or comedones
• ⬜ Skin growths (freckles, moles, or birth mark)
• ⬜ Excessive hair growth
• ⬜ Evidence of skin trauma (scar, laceration, or bruising)
• ⬜ Drooping eye
• ⬜ Drooping mouth

✅ Inspected Eyes

Eyelids

• ✅ No visible abnormal findings
• ⬜ Ptosis
• ⬜ Swelling
• ⬜ Lesion
• ⬜ Allergic shiners

Conjunctiva and lens

• ✅ No visible abnormal findings
• ⬜ Sclera - injection
• ⬜ Sclera - icterus
• ⬜ Lens opacification

Pupillary reaction

• ✅ No visible abnormal findings (PERRL)
• ⬜ Unequal
• ⬜ Irregular
• ⬜ Miosis
• ⬜ Mydriasis
• ⬜ Non-reactive to light

⚠️ Inspected Mouth (section not v-marked — NOT completed)

Oral mucosa and Gums — not assessed Lips — not assessed Tongue — not assessed

⚠️ Instructor Note: Oral mucosa assessment is a standard admission exam item. Complete this section — especially relevant for hydration status monitoring in CKD.

✅ Inspected Hips

Appearance

• ✅ No visible abnormal findings
• ⬜ Edema
• ⬜ Erythema
• ⬜ Visible mass
• ⬜ Irregular alignment
• ⬜ Pelvic tilt

✅ Inspected Thighs

Right: Appearance

• ✅ No visible abnormal findings
• ⬜ Redness
• ⬜ Bruising or other discoloration
• ⬜ Edema
• ⬜ Visible mass
• ⬜ Atrophy
• ⬜ Hypertrophy

Left: Appearance

• ✅ No visible abnormal findings
• ⬜ Redness
• ⬜ Bruising or other discoloration
• ⬜ Edema
• ⬜ Visible mass
• ⬜ Atrophy
• ⬜ Hypertrophy

Symmetry

• ✅ Symmetric bilaterally
• ⬜ Asymmetric

✅ Inspected Knees

Alignment

• ✅ Normal alignment of femur and tibia
• ⬜ Varus deformity
• ⬜ Valgus deformity

Left Knee: Appearance

• ✅ No abnormal findings
• ⬜ Visible swelling
• ⬜ Erythema
• ⬜ Visible mass
• ⬜ Genu recurvatum

Right Knee: Appearance

• ✅ No abnormal findings
• ⬜ Visible swelling
• ⬜ Erythema
• ⬜ Visible mass
• ⬜ Genu recurvatum

✅ Inspected Lower Legs

Right: Appearance

• ✅ No visible abnormal findings
• ⬜ Redness
• ⬜ Bruising or other discoloration
• ⬜ Edema
• ⬜ Visible mass
• ⬜ Atrophy
• ⬜ Hypertrophy

Left: Appearance

• ✅ No visible abnormal findings
• ⬜ Redness
• ⬜ Bruising or other discoloration
• ⬜ Edema
• ⬜ Visible mass
• ⬜ Atrophy
• ⬜ Hypertrophy

Symmetry

• ✅ Symmetric bilaterally
• ⬜ Asymmetric

✅ Inspected Skin

Wounds or sores

• ✅ No abnormal findings
• ⬜ Abrasion
• ⬜ Laceration
• ⬜ Exposed wounds or cuts
• ⬜ Sore or pressure ulcer

Signs of skin trauma

• ⬜ No abnormal findings
• ✅ Bruising (lower back — r/t fall this AM)
• ⬜ Burn
• ⬜ Ligature mark
• ⬜ Scarring

Color or appearance

• ⬜ No abnormal findings
• ⬜ Purpura or petechiae
• ✅ Redness (lower back erythema — r/t fall)
• ⬜ Jaundice
• ⬜ Rash
• ⬜ Freckles, birthmarks, melasma, or other lesions

Masses or texture

• ✅ No abnormal findings
• ⬜ Visible masses (warts, cysts, or tumors)
• ⬜ Varicosities
• ⬜ Striae
• ⬜ Moles or skin tags

Skin characteristics and hair growth

• ✅ No abnormal findings
• ⬜ Excessive dry or flaking skin
• ⬜ Excessive hair growth

✅ Auscultated Carotids

Right

• ✅ No bruit
• ⬜ Bruit

Left

• ✅ No bruit
• ⬜ Bruit

✅ Auscultated Breath Sounds

Breath sounds

• ✅ Clear in all areas
• ⬜ Diminished in some areas
• ⬜ Absent in some areas

Adventitious sounds

• ✅ No adventitious sounds
• ⬜ Wheezing
• ⬜ Fine crackles
• ⬜ Stridor
• ⬜ Rhonchi
• ⬜ Rales

✅ Auscultated Heart Sounds

Heart sounds

• ✅ S1 and S2 audible
• ⬜ S1, S2, and S3 audible
• ⬜ S1, S2, and S4 audible
• ⬜ S1, S2, S3, and S4 audible

Extra heart sounds

• ✅ No extra sounds
• ⬜ Gallops
• ⬜ Murmur
• ⬜ Friction rub
• ⬜ Valve clicks

Rate and rhythm

• ⬜ Regular rate and rhythm
• ⬜ Irregular rate
• ✅ Arrhythmia (consistent with known chronic Afib)

✅ Palpated PMI

Location

• ✅ Present at midclavicular line and 5th intercostal space
• ⬜ Displaced laterally right
• ⬜ Displaced laterally left

Size

• ✅ < 2 cm (penny or dime sized)
• ⬜ > 2 cm (quarter sized)

Characteristics

• ✅ Brisk and tapping
• ⬜ Increased amplitude (hyperdynamic)
• ⬜ Sustained
• ⬜ Double impulse
• ⬜ Heaving

✅ Palpated Knees

Right

• ⬜ No abnormal findings
• ⬜ Sensation of warmth
• ✅ Reported tenderness
• ⬜ Effusion
• ⬜ Bony swelling
• ✅ Crepitus, popping or clicking
• ⬜ Contractures

Left

• ⬜ No abnormal findings
• ⬜ Sensation of warmth
• ✅ Reported tenderness
• ⬜ Effusion
• ⬜ Bony swelling
• ✅ Crepitus, popping or clicking
• ⬜ Contractures

✅ Palpated Posterior Tibial Pulse

Right: Vibration

• ✅ No thrill
• ⬜ Thrill

Right: Amplitude

• ⬜ 0 Absent
• ⬜ 1+ Diminished or barely palpable
• ✅ 2+ Expected
• ⬜ 3+ Increased
• ⬜ 4+ Bounding pulse

Left: Vibration

• ✅ No thrill
• ⬜ Thrill

Left: Amplitude

• ⬜ 0 Absent
• ⬜ 1+ Diminished or barely palpable
• ✅ 2+ Expected
• ⬜ 3+ Increased
• ⬜ 4+ Bounding pulse

✅ Palpated Dorsalis Pedis Pulse

Right: Vibration

• ✅ No thrill
• ⬜ Thrill

Right: Amplitude

• ⬜ 0 Absent
• ⬜ 1+ Diminished or barely palpable
• ✅ 2+ Expected
• ⬜ 3+ Increased
• ⬜ 4+ Bounding pulse

Left: Vibration

• ✅ No thrill
• ⬜ Thrill

Left: Amplitude

• ⬜ 0 Absent
• ⬜ 1+ Diminished or barely palpable
• ✅ 2+ Expected
• ⬜ 3+ Increased
• ⬜ 4+ Bounding pulse

✅ Tested Fine Motor Skills

Observations at rest (arms and hands at patient’s side)

• ✅ Able to perform without difficulty; no tremor
• ⬜ Tremor
• ⬜ Performed with difficulty
• ⬜ Unable to perform

Observations with held posture (forward extension of arms)

• ✅ Able to perform without difficulty; no tremor
• ⬜ Tremor
• ⬜ Performed with difficulty
• ⬜ Unable to perform

Observations with movement (nose to finger test)

• ✅ Able to perform without difficulty; no tremor
• ⬜ Tremor
• ⬜ Performed with difficulty
• ⬜ Unable to perform

✅ Tested Cognition (Mini-Cog)

Clock Drawing Test

• ✅ All numbers present in correct sequence and position; hands display requested time — 2 points
• ⬜ Missing or incorrectly placed numbers, or hands do not display requested time — 0 points

Word Recall

• ✅ Correctly recalled three words — 3 points
• ⬜ Correctly recalled two words — 2 points
• ⬜ Correctly recalled one word — 1 point
• ⬜ Correctly recalled zero words — 0 points

Mini-Cog Total: 5/5 — Negative for cognitive impairment

✅ Tested Hip Strength

Strength (bilateral)

• ⬜ 0 — No muscle contraction
• ⬜ 1 — Barely detectable contraction
• ⬜ 2 — Active movement with gravity eliminated
• ⬜ 3 — Active movement against gravity
• ✅ 4 — Active movement against gravity and resistance
• ⬜ 5 — Active movement against full resistance without fatigue (normal)

✅ Tested Knee Strength

Right

• ⬜ 0 — No muscle contraction
• ⬜ 1 — Barely detectable contraction
• ⬜ 2 — Active movement with gravity eliminated
• ⬜ 3 — Active movement against gravity
• ✅ 4 — Active movement against gravity and resistance
• ⬜ 5 — Active movement against full resistance without fatigue (normal)

Left

• ⬜ 0 — No muscle contraction
• ⬜ 1 — Barely detectable contraction
• ⬜ 2 — Active movement with gravity eliminated
• ⬜ 3 — Active movement against gravity
• ✅ 4 — Active movement against gravity and resistance
• ⬜ 5 — Active movement against full resistance without fatigue (normal)

✅ Tested Hip Range of Motion

Flexion (approx. 90°)

• ⬜ Expected range of motion
• ✅ Reduced hip flexion

Extension (approx. 30°)

• ⬜ Expected range of motion
• ✅ Reduced hip extension

Abduction (approx. 45°)

• ⬜ Expected range of motion
• ✅ Reduced hip abduction

Adduction (approx. 30°)

• ⬜ Expected range of motion
• ✅ Reduced hip adduction

✅ Tested Knee Range of Motion

Right: Flexion (approx. 130°)

• ⬜ Expected range of motion
• ✅ Reduced flexion

Left: Flexion (approx. 130°)

• ⬜ Expected range of motion
• ✅ Reduced flexion

Right: Extension (approx. 0–15°)

• ⬜ Expected range of motion
• ✅ Reduced extension

Left: Extension (approx. 0–15°)

• ⬜ Expected range of motion
• ✅ Reduced extension

✅ Tested Skin Turgor

Observations

• ✅ No tenting (hydration adequate)
• ⬜ Tenting

✅ Tested Capillary Refill

Capillary refill time

• ✅ Less than 2 seconds (normal peripheral perfusion)
• ⬜ Greater than 2 seconds

✅ Tested Gait

Initiation of gait

• ⬜ No hesitancy
• ✅ Hesitancy or multiple attempts to start

Step length

• ⬜ Stepping foot passes stationary foot
• ✅ Stepping foot does not pass stationary foot

Step height

• ⬜ Steps clear floor
• ✅ Steps do not clear floor completely

Step symmetry

• ⬜ Right and left step length equal
• ✅ Right and left step length unequal

Step continuity

• ⬜ Steps are continuous
• ✅ Discontinuity between steps

Path

• ⬜ No deviation of path
• ✅ Some path deviation or use of walking aid
• ⬜ Significant path deviation

Trunk

• ⬜ No sway, no flexion, no use of arms, and no use of walking aid
• ⬜ No sway, flexion of knees or back, or arms spread out while walking
• ✅ Observable sway or use of walking aid

Walking stance

• ✅ Heels set apart (wide base — compensatory for pain and instability)
• ⬜ Heels almost touching while walking

Time to complete test

• ⬜ Less than or equal to 12 seconds (normal mobility)
• ✅ Greater than 12 seconds — increased likelihood of falls (confirms high fall risk)

Instructor Summary — Objective Exam:

• ✅ IV bag/pump/site fully assessed and confirmed safe — scored patient safety item; demonstrates systematic nursing practice
• ✅ BP hypertensive — expected with HTN + acute pain
• ✅ HR bradycardic — correctly attributed to verapamil (CCB rate control for Afib)
• ✅ Arrhythmia documented — consistent with chronic Afib; essential baseline given apixaban therapy
• ✅ No carotid bruits — supports mechanical fall etiology over vascular/syncopal origin
• ✅ Lungs clear — no respiratory compromise; safe context for morphine use
• ✅ PERRL — neurologically intact post-fall
• ✅ PMI normal location, size, brisk — no cardiac enlargement
• ✅ Peripheral pulses 2+ bilaterally — rules out PVD as pain contributor
• ✅ Bilateral knee tenderness + crepitus — hallmark OA findings on palpation
• ✅ Hip and knee strength 4/5 bilaterally — functional deficit, explains fall mechanism
• ✅ All hip and knee ROM reduced bilaterally — confirms functional limitation
• ✅ Fine motor intact — no Parkinsonism, no cerebellar deficit
• ✅ Mini-Cog 5/5 — normal cognition; important baseline with opioid on board
• ✅ Skin turgor intact; capillary refill < 2 sec
• ✅ Skin: bruising and redness at lower back — fall sequelae confirmed
• ✅ Gait > 12 sec with hesitancy, sway, discontinuity, wide stance — objectively confirms high fall risk — use this score in your care plan
• ⚠️ Mouth not assessed — complete before finishing the sim; oral mucosa hydration relevant with CKD
• ⚠️ Head/face section not v-marked — verify completion and confirm no fall-related facial trauma documented

Priority Nursing Diagnosis (PES Format)

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Short-Term Goal

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Interventions & Rationale

Evaluation

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CJMM: Take Action / Evaluate Outcomes

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Education & Empathy Log

Key Teaching Points (Running Log)

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Student Strengths Noted

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Areas to Revisit

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SBAR Hand-Off to Preceptor Diana