Surg Case 1 Marilyn Hughes- Alexa Bailey PDF

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outline of study guide for first med surg test...

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Surgical Case 1: Marilyn Hughes Documentation Assignments 1. Document a comprehensive pain assessment for Marilyn Hughes. Marilyn was in a large amount of pain, after I introduced myself, I could barely finish before she let me know that there was pain in her left leg. Her body language was uncomfortable and the tone in her voice led me to believe it was getting worse. She stated that the pain was 8/10. Her skin was cold and sweaty. Once I sat her up in the bed and lower her leg from the pillows, I noticed a change in her tone. I assessed the dressing and realized that it was tight, I loosened the dressing, and her pain was then stated to be a 5/10, which meant it has decreased from the initial 8/10 but was still there. 2. Document Marilyn Hughes’ neurovascular assessment. I asked Marilyn if she could move or feel her toes, the answer to both was no. She stated that she left leg felt numb and hurt more when I touched it. The pedal pulse was absent on the left foot and bounding at 95 beats per minutes on the right side. 3. Document the changes in Marilyn Hughes vital signs. The vital signs that I received when I first came into the room and started the assessment were RR:21, HR: 94, SpO2: 98, BP:150/90, Radial Pulse:95 bounding, regular and a temperature of 99` F. After I performed nursing interventions the vital signs changed. When I took the vital signs again some were at a more regular state- RR: 16, HR:87, SpO2:97, Radial Pulse:90 strong and regular, BP: 150/90, temp:99` F. 4. Identify and document key nursing diagnoses for Marilyn Hughes. -

Acute Pain r/t pressure in the compromised body part as evidenced by pulselessness.

- Risk for impaired Skin Integrity r/t positioning. 5. Referring to your feedback log, document the nursing care you provided and Marilyn Hughes’ response to this care. I provided Marilyn with a focused assessment on the injured/painful body part. Her left leg was the body part that was feeling pain so that it where I began the focused assessment. Once I assessed the problem, I went back and assessed the rest of the body. I took the vital signs and then communicated them to the physician. Then I went back and did some nursing interventions. I sat the bed up to a more comfortable position and lowered the legs from the pillows. I loosened the dressings which was a main concerned

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of the patient. To try to comfort her and make her feel more relaxed in this time of care, I offered her a cup of water. Then I went back and asked her how it felt now that I loosened the dressing. Her pain had subsided by a little. The vital signs were taken again, and they showed a decrease as well. Her response was a positive feedback that the nursing interventions had worked but had not taken care of the problem completely, she was still in pain. I relayed the information to the physician again so that he could put that towards the diagnosis.

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