Sara Lin Documentation Assignments PDF

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Sara Lin Documentation Assignments...

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Sara Lin Documentation Assignments 1. Document your focused pain assessment of Sara Lin. I took patient’s vital signs:  Blood Pressure: 138/82  Radial Pulse: 98 BPM  Temperature: 99° F (Temperature was high and – according to skin assessment – the patient was very sweaty, so I gave her some water.)  Respirations: 21 BPM  SpO2: 98%  Pain Scale (1-10): 5 When asked if anything makes the pain better, the patient stated, “if I lay perfectly still, it is better”. When asked if anything makes the pain worse, the patient stated, “Yes, it gets worse by deep breathing and coughing.” 2. Document your priorities for care of this patient. Take vital signs, assess pain, administer pain medication per physician orders, assess incision and dressing, and provide education regarding incentive spirometer, incision (wound) care and signs of infection, activity restrictions, and medications (pain and antibiotics). 3. Document two nursing diagnoses for this patient. - Acute pain due to surgical incision, as mentioned in the patient’s statement, “The pain is sharp on my side. My belly hurts and kind of throbs.” -Readiness for enhanced knowledge expresses an interest in learning once she goes home, as mentioned in the patient’s statement, “I want to know how much I can do at home.” 4. Document patient education regarding pain management for this patient. The patient was alsoeducated on safety and activities. She was advised not to operate heavy machinery or drive while taking pain medication. She was also educated about medication. The patient was advised to take all medications as directed by physician. The patient should have also been educated on wound (incision) care, and advised to contact physician in the event ofincreased drainage, redness, and swelling around the incision site. 5. Referring to your feedback log, document the nursing care you provided to Sara Lin

and her response. I began by introducing myself, identifying the patient, and washing my hands. I then From vSim for Nursing | Fundamentals. © Wolters Kluwer

proceeded to ask the patient if she had any allergies. Knowing I would be checking the patient’s skin while taking vital signs, I put on gloves. I then attached the pulse oximeter to measure oxygen levels while I completed remaining vitals. The patient’s oxygen levels were at 98% consistently throughout the simulation. I then checked the patient’s respirations, which were 21 breaths per minute. The patient also had a strong radial pulse, at 100 beats per minute. I examined the patient’s skin next, with results showing normal elasticity. However, the patient had cool but sweaty skin. I then took her temperature, which came back as 99° F. The last remaining vital sign to take was blood pressure, which came back as 138/82 mm Hg. Next, I directed the patient to use the incentive spirometer, as indicated by the provider’s orders. Because the patient’s temperature was slightly elevated and her skin was very sweaty, I assisted her into a high sitting position and gave her a sip of water. I then checked her MAR, and began administering the ordered medications. I began with 5 mg of oxycodone orally, as indicated by the patient’s MAR. This was followed by 325 mg of acetaminophen orally, also indicated by the patient’s MAR. The final administered medication during the simulation was the ordered 500 mg of levofloxacin, which was given orally. I then asked the patient if she was in any pain, and asked her to rate her pain on a scale of 1-10. She told me her pain fell at a 5 on the scale, and deep breathing and coughing only makes her pain worse. She did, however, state that laying perfectly still makes the pain a little better. I then educated the patient about the use of an incentive spirometer. This was followed by auscletation of the patient’s abdomen, which resulted in normal bowel sounds. I continued the patient’s education with information about medication, as well as activities, safety, and fall risk. Once the pain medications had some time to start working, I asked the patient to describe her pain. She explained that the pain is sharp in her side, and her belly hurts and has begun to throb. I asked if the patient needed anything else for the pain, and she enthusiastically said “Yes, please!”. I decided to call the provider to let them know the patient is still in a lot of pain, despite the pain medications. The provider decided to keep the orders the same, so I completed the patient handoff.

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