Sample Assessment documentation v Sim PDF

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vSim Health Assessment Case 1: Josephine Morrow Documentation Assignments – EXAMPLE 1. Document Ms. Morrow’s skin assessment using the Braden scale. - Assessed Ms. J.M’s risk of developing pressure ulcers using the Braden scale. She scored 16, indicating mild risk. - Sensory Perception: 2, Moisture: 4, Activity: 2, Mobility: 2, Nutrition: 3, Friction and shear: 2 = 16 - Patient responds to verbal commands, but has limited ability when it comes to feeling any pain or itchiness on her right lower leg. Most of the patient’s skin, tongue & mucous membranes are dry. She has impaired mobility and requires assistance with positioning in bed and when ambulating. Patient tries to meet her daily nutritional needs. There is also a potential problem for friction and shearing as the patient requires assistance when transferring or positioning. - She is at risk for pressure ulcers as she has impaired mobility. 2. Document the teaching on promoting circulation that you provided to Ms. Morrow. - Educated the patient the importance of getting up and walking around at least two times a day to promote the circulation in her legs. Also, elevating her legs and wiggling her feet up and down while in bed or in a chair. Patient should also use compression stockings so that she can improve the venous return. 3. Document your assessment of Ms. Morrow’s skin for the charge nurse using the SBAR format. Situation

Ms. Josephine Morrow, is an obese, 80-yearold female who developed a venous stasis ulcer on her right lower extremity. Bilateral brown hyperpigmentation onlower legs with pitting edema 2+. Lab hepatic function tests are lower than the normal range.

Background

Past medical history of COPD, chronic venous insufficiency, and deep vein thrombosis. Allergic to Penicillin; gets rashes from it. She moved here recently due to concern for her safety as she has impaired mobility, From vSim for Nursing | Health Assessment. © Wolters Kluwer.

unhealthy diet, and inability to care for herself. Assessment

Ms. Josephine is alert and oriented. Mobility: Pt requires assistance with positioning in bed, transferring and when ambulating. Pt has unsteady gait. Nutrition: Pt is on a regular diet with nutritional supplement to promote wound healing. Vital signs are within normal range. Lab hepatic function results was lower than the normal range. Skin: Full body skin assessment completed; noted thinning hair on the patient’s head. Some fine hair on the lower arm. Pt looks dehydrated as tongue, lips, and mucous membranes are a bit dry. Skin on both lower legs was shiny, cool, and dry with brown hyperpigmentation and pitting edema 2+. Patient’s wound dressing on her right lower leg was clean, dry and intact. On both feet, there was moderate edema but no signs of redness. The skin’s appearance on both feet are shiny, dry and cool to touch with pitting edema. Capillary refill time on the patient’s fingers and toes was less than 3 seconds. Braden scale assessment was done and she scored 16, indicating mild risk. Pain: Subjective - When asked if she feels any pain she stated “I don’t have any pain.” Patient reports she gets easily fatigue.

From vSim for Nursing | Health Assessment. © Wolters Kluwer.

Recommendation

Monitor Ms. Morrow’s hair and both lower legs; check if there’s any changes on the appearance and the temperature of both legs. Plan to maintain good skin integrity making sure that skin is moisturized. Review lab hepatic function tests as well to check if there’s any changes. Encourage her to drink her fluids and eat foods that are high in protein. Provide patient education on promotion of circulation and the importance of protein in her wound healing.

4. Document the dietary teaching you provided to Ms. Morrow to promote wound healing. - Encouraged the patient to choose a high-protein diet and to drink her protein shakes as ordered by the provider as this supplemental protein is needed to promote wound healing.

From vSim for Nursing | Health Assessment. © Wolters Kluwer....