Jared Griffin Documentation Assignment PDF

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Jessica Bridges NUR104 Clinicals

Jared Griffin Documentation Assignments 1. Document your finding related to Mr. Griffin's preoperative and postoperative assessment findings regarding the presence of an infection. Mr. Griffin has a history of MRSA, which was diagnosed 3 years ago before when having surgery for a hammertoe. During his preoperative assessment a nasal swap was done in office and came back positive for MRSA. Durning his postoperative assessment his vitals were Temp 98 degrees F, BP 132/80, RR 15, Pulse 80, SaO2 97%. His dressing was clean & dry, no signs of drainage, swelling, redness, or warmth to touch, and his WBC is 11. At this time the patient is not showing any signs of infection. 2. Identify and document key nursing diagnoses for Mr. Griffin regarding current condition. Delayed surgical recovery related to infection. Ineffective peripheral tissue fusion related to surgery. Risk for periphereral neurovascular dysfunction related to surgical procedure. Impaired tissue integrity regarding to wound, infection. Impaired physical mobility related to musculoskeltal impairment, surgery, prothesis. Activity intolerance related to pain, surgical procedure. Risk for constipation related to decreased activity, anesthesia, pain medication. 3. Referring to your feedback log, document all nursing care provided as well as Mr. Griffin's response to this care, including responses related to infection control and the use of personal protective equipment (PPE). I reviewed the electronic medical record for Jared Griffin, DOB: 4-7-57. Before entering the patients room I preformed hand hygiene, and donned gloves and a gown. Introduced myself, verified patients name & DOB, and allergies. Patient stated he has an allergy to codeine. He oriented to place & date. Patient is A&O x4.Vital signs were Temp 98 degrees F, BP 137/80, RR 15, Pulses- radial 80, strong & regular, pedal- 80, strong & regular, SaO2 97%, capillary refill less than 2 seconds. Skin color & elasticity are normal, he is not sweating, there is a dressing cover over the skin lesion on right lower leg. Asked patient if he had any pain, he stated yes, I am feeling a little sore in my knee, asked the patient if anything made the pain better, he stated no, not really, asked if anything made it worse, he stated it hurts a little when I bend the knee, asked if he could vSim for Nursing | Fundamentals. © Wolters Kluwer

describe the pain, he stated no, not really, asked the patient to rate his pain, he stated not to bad it’s about a 2. Lungs are clear and equal bilaterally. Heart sounds are regular without murmurs. Assessed IV site, there is no redness, swelling, infilitration, bleeding, or drainage, dressing was dry & intact. Assessed surgical dressing for infection it was dry & clean. Patient was compliant with use of incentive spirometer per physicians orders. Educated the patient regarding activities, safety, fall risk, personal protective equipment, using the incentive spirometer, and wound care. Patient verbalized the understanding for education in each of these areas. 4. Document your handoff report in the SBAR format to communicate Mr. Griffin's future needs. S- Jared Griffin is a 63 year old African American male who had a right total knee arthroplasty yesterday morning. --------------------------------------------------------------------B- Mr. Griffin has a history of MRSA, which was diagnosed 3 years ago when he had a surgery for a hammertoe. He has a history of osteoarthritis & mild hypertension. A nasal swab was done in office during his recent preoperative visit and came back positive for MRSA. Decolonization protocol was initiated prior to his admission for the right total knee arthroplasty. He is currently under contact precautions per hospital policy. ----------A- Mr. Griffin’s vitals are stable, he is A&O x4, and he has a pain level of 2/10. Assessed IV & surgical site for infection, there is no signs of redness, swelling, bleeding, or drainage. The dressings are dry, clean, and intact. Used the incentive spirometer as ordered. ------------------------------------------------------------------------------------------------R- Continue to monitor Mr. Griffin’s vital signs and pain level. Administer pain -----------medication prn per physicians order. Continue to assess IV and surgical site and dressings for signs of infection. Encourage continuous use of incentive spirometer. Continue with contact precautions per hospital policy--------------------------- J. Bridges, Nursing Student

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