SurgicalCase01_MarilynHughes_DA.docx - Amanda Durant MS2 Nursing Clinical Wk 4 Surgical Case 1 Marilyn Hughes Documentation Assignments 1 Document a

SurgicalCase01_MarilynHughes_DA.docx - Amanda Durant MS2...

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Amanda Durant MS2 Nursing Clinical Wk 4 Surgical Case 1: Marilyn Hughes Documentation Assignments 1. Document a comprehensive pain assessment for Marilyn Hughes. Patient states her leg is in pain even after IV Morphine, on a scale of 0-10 it is a 5, pain increases with passive movement, slightly better after leg lowered and dressing loosened 2. Document Marilyn Hughes’ neurovascular assessment. Pedal pulse normal +2 RLE, absent in the LLE, patient cannot move or feel toes in LLE, slightly cyanotic and cool to touch, patient reports it is numb 3. Document the changes in Marilyn Hughes vital signs. BP is elevated, slightly decreased after dressing loosened but remains elevated 4. Identify and document key nursing diagnoses for Marilyn Hughes. Risk for ineffective tissue perfusion. Risk for acute pain. Risk for impaired physical mobility. 5. Referring to your feedback log, document the nursing care you provided and Marilyn Hughes’ response to this care. You arrived at the patient's side. 0:00 You introduced yourself. 0:09 You washed your hands. To maintain patient safety, it is important to wash your hands as soon as you enter the room. 0:10 Patient status - ECG: Sinus tachycardia. Heart rate: 108. Pulse: Present. Blood pressure: 151/91 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 97%. Temp: 99 F (37 C) 1:10 Patient status - ECG: Sinus tachycardia. Heart rate: 109. Pulse: Present. Blood pressure: 154/93 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 1:19 You identified the patient. To maintain patient safety, it is important that you quickly
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  • Fall '17
  • pulse, sinus tachycardia, Wolters Kluwer

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