Lloyd Bennett DA PDF

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Surgical Case 5: Lloyd Bennett Documentation Assignments 1. Document your focused postoperative assessment for Lloyd Bennett. a. VS assessed: Heart rate: 94. Pulse: Present. Blood pressure: 110/71 mm Hg. Respiration: 17. SpO2: 94%. Temp: 99 F (37 C). Patient is awake and oriented. Normal skin turgor and pale color. Normal heart and lung sounds upon auscultation. Assessed patient’s dressing site, no abnormalities noted. Assessed IV site, no redness, swelling, infiltration, bleeding, or drainage noted. 2. Document Lloyd Bennett’s allergies in his chart. a. Patient experienced acute transfusion reaction during administration of packed red blood cells. 3. Document Lloyd Bennett’s vital signs during the transfusion reaction. a. Initial VS: Heart rate: 92. Pulse: Present. Blood pressure: 106/69 mm Hg. Respiration: 17. SpO2: 94%. Temp: 99 F (37 C) b. VS following blood transfusion: Heart rate: 97. Pulse: Present. Blood pressure: 114/73 mm Hg. Respiration: 19. SpO2: 94%. Temp: 99 F (37 C) 4. Document the priority nursing actions completed during the transfusion reaction. a. Transfusion stopped. Assessed for pain and other symptoms. Phoned provider to discuss patient. Provided patient education. Obtained urine dipstick and culture. Obtained venous blood sample. Flushed IV cannula and started infusing NS at 100 mL/hr per order. Contacted blood bank. Assessed VS and auscultated heart and lung sounds. Reassessed pain and other symptoms. 5. Identify and document key nursing diagnoses for Lloyd Bennett. a. Risk for Imbalanced Body Temperature b. Anxiety c. Risk for Injury

6. Referring to your feedback log, document the nursing care you provided. 1030 Introduced self to patient, washed hands, identified patient and assessed for allergies. 1032 Sat patient up in bed and provided education. 1034 Obtained informed consent. 1035 Assessed VS, skin, lung sounds and heart sounds. 1037 Assessed patient dressing and IV site.

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1039 Flushed IV cannula and started infusing packed red blood cells per order at 100 mL/hr. 1040 Patient started to develop a transfusion reaction so infusion was stopped. 1041 Assessed patient’s back pain and other symptoms. 1042 Phoned provider to discuss the patient and new orders were placed. 1043 Obtained urine dipstick and culture, and venous blood sample per order. 1045 Flushed IV cannula and started infusing NS at 100 mL/hr per order. 1046 Contacted the blood bank. 1047 Assessed VS and auscultated heart and lung sounds. 1050 Reassessed pain and other symptoms. 1051 Phoned provider to discuss the patient. 1052 Handoff performed.

© Wolters Kluwer Health | Lippincott Williams & Wilkins...