Josephine Morrow Documentation Assignment PDF

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Jessica Bridges NUR104 Clinicals

Josephine Morrow Documentation Assignments 1. Document the findings of a focused skin assessment of Ms. Morrow, including any findings that identify the presence of chronic venous insufficiency. Upon skin assessment, the patients skin color is normal for ethnicity and intact, except she does have brown hyperpigmentation bilaterally from the knees and down both sides with 2+ edema. She has venous stasis ulcer on the right medial malleolus, it is covered with a hydrocolloid dressing. Skin is dry, elasticity is normal, and there is no evidence of tenting. Pedal and radial pulses were 95, strong and regular. The dressing was removed and the wound was assessed and documented. Wound was irrigated and a new dressing applied. 2. Document any abnormal laboratory results that are associated with the presence or status of Ms. Morrow's stasis ulcer. The patients albumin level was a 3.4 g/dL, slightly below normal (normal values 3.5-5.0 g/dL). Decreased albumin levels can impact the wound healing process. Her prealbumin level was 14.7 mg/dL, significantly below level (normal values 19-38 mg/dL). Decreased prealbumin levels can come from inflammation and/or wounds, like a stasis ulcer. 3. Record the results of Ms. Morrow's Braden Scale assessment. The patients Braden Scale is 16, and her skin is intact except for the venous stasis ulcer on the right medial malleolus. This puts her at moderate risk for an acquired pressure ulcer. 4. Document the characteristics of Ms. Morrow's venous stasis ulcer. The ulcer is shallow, 1 inch in width, and mostly looks pink to red, with no signs of necrosis or infection.

From vSim for Nursing | Fundamentals. © Wolters Kluwer

5. Document the dressing change and irrigation of Ms. Morrow’s wound. The patient was medicated 30 minutes prior to dressing change. Assessed the current dressing, it was clean, dry, and intact. The hydrocolloid dressing was removed and the ulcer was assessed. The findings were documented. The ulcer was irrigated with normal saline and a new hydrocolloid dressing was applied. Compression stockings were put on and elevated her legs. Areas around the ulcer should be monitored daily. The ulcer itself should be irrigated and the dressing changed every 3 days. 6. In the chart, record patient education on ways to promote venous return. Patient education on ways to promote venous return included getting up and walking around regularly, avoid prolonged sitting or standing, elevate their legs, and wiggle their feet up and down while in the bed or sitting in a chair. Compression stockings should be used as well to help promote venous return.

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