Jared Griffin NUR192 PDF

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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’s preoperative assessment has shown signs of an infection. During the preoperative assessment, there was a nasal swab conducted and was positive for MRSA. Mr. Griffin’s postoperative assessment has shown no signs of an infection, based on the vital signs being stable and temperature within acceptable range. 2. Identify and document key nursing diagnoses for Mr. Griffin regarding current condition. One main nursing diagnosis for Mr. Griffin would be delayed surgical recovery related to MRSA. Another primary nursing diagnosis would be activity intolerance related to undergoing postoperative care of TKA surgery. Mr. G is experiencing decreased ROM related to being postoperative, especially going through TKA surgery and already being 63-years-old. Also, anxiety related to Mr. G being in a hospital environment, and having undergone TKA surgery. Acute pain related to inflammation/injury in surgery area. 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). Mr. G is a 63-year-old male. I reviewed patient record and information, washed my hands, put on gloves and gown, introduced myself, verified name and DOB, he responded appropriately. Has a codeine allergy. Respirations-15/min. Pulse- radial, 80/min, strong, regular; pedal- 80/min, strong, regular. BP-137/81 mm/Hg. Temp- 98 degrees F. SpO2: 97%. Cap. Refill- less than two seconds. 2/10 pain in knee. Skin is dry, warm, elasticity is normal, color is normal, with a dressing on the skin lesion on lower leg. Mr.G was compliant with the assessment of vital signs. I assessed patient’s dressing to see if there was any signs of infection, the dressing was dry and clean. Mr. G willingly used the incentive spirometer that was ordered. Assessed the patient’s IV, there was no redness, swelling, infiltration, bleeding, or drainage. The dressing was intact and dry. I then took the time to educate the patient regarding activities, safety, fall risk, personal protective equipment, incentive spirometer, and wound care. 4. Document your handoff report in the SBAR format to communicate Mr. Griffin's future needs. Situation: Jared Griffin is a 63-year-old African American male who had a right total knee arthroplasty (TKA) yesterday morning. vSim for Nursing | Fundamentals. © Wolters Kluwer

Background: Mr. Griffin has a history of MRSA, which was diagnosed 3 years ago when he had surgery for a hammertoe. A nasal swab was done in the office during his recent preoperative check that came back positive for MRSA. Decolonization protocol was initiated prior to the admission for the total knee procedure and he is currently under contact precautions per hospital policy. He has a history of osteoarthritis and mild hypertension. Assessment: Mr. G’s vital signs have been stable, 2 pain level, checked dressings and there are no signs of infection. Mr. G has an IV hook up and a dressing on right lower leg from surgery. Has kept up with incentive spirometer. Recommendation: Keep an eye on Mr. G’s pain level and vital signs. Also look for signs of infection and check on the dressings. Continue with contact precautions.

vSim for Nursing | Fundamentals. © Wolters Kluwer...