University:
Stevenson University
Course:
NURS 460 | Medical/Surgical Nursing II
Academic year:

2020
Views:

223

Pages:

2
Author:

Alma Hester

Sara Lin Documentation Assignments 1. Document your focused pain assessment of Sara Lin. - Pain assessment: took patient’s vital signs – BP: 136/80, monitor pulse: 98 bpm, pedal pulse: 100 bpm, temp: 99 F, respirations: 21, SpO2: 98%. When presented with 0-10 pain scale, patient stated pain level at 6. “The pain is sharp on my side. My belly hurts and kind of throbs.” 2. Document your priorities for care of this patient. - Take vital signs. - Assess pain. - Administer pain medication per physician orders. - Assess incision and dressing. - Provide education regarding incentive spirometer, incision (wound) care and signs of infection, activity restrictions, medications (pain and antibiotics). 3. Document two nursing diagnoses for this patient. - Acute pain r/t surgical incision AEB patient statement: “The pain is sharp on my side. My belly hurts and kind of throbs.” -Readiness for enhanced knowledge expresses an interest in learning AEB patient statement: “I want to know how much I can do at home.” 4. Document patient education regarding pain management for this patient. - Patient was educated on wound (incision) care. Was advised to contact physician in the event of increased drainage, redness, and swelling around the incision site. - Patient was educated on safety and activities. Was advised not to operate heavy machinery or drive while taking pain medication. - Patient was educated on medication. Was advised to take all medications as directed by physician. 5. Referring to your feedback log, document the nursing care you provided to Sara Lin and her response. - Introduced self, washed hands, identified patient, put on gloves, verified that patient had no allergies. - Performed pain assessment. Patient stated pain was “pretty bad” and 6/10. - Took vitals. BP: 136/80, monitor pulse: 98 bpm, pedal pulse: 100 bpm, temp: 99 F, respirations: 21, SpO2: 98%. - Compared medication label with MAR, gave 5 mg oxycodone orally as prescribed. - Performed pain assessment. Patient stated pain was “pretty bad” and 5/10. - Listened to lungs; breath sounds clear and equal bilaterally. - Listened to heart; heart sounds were regular and without murmurs. - Listened to abdomen; normoactive bowel sounds in all four quadrants. - Respirations: 21 breaths per min., chest moved equally. - Performed pain assessment. Patient stte pain was “pretty bad” 5/10. - Checked pedal and radial pulses; pulse strong, 100/min and regular/ - Assessed IV site, no redness, swelling, infiltration, bleeding, or drainage. - Dressing dry and intact. - Assessed abdominal incision. - Patient used incentive spirometer. - Compared medication label to MAR, gave 325 mg acetaminophen orally as prescribed. - Compared medication label to MAR, gave 500 mg levofloxacin orally as prescribed. - Performed pain assessment. Patient stated pain was still 5/10. - Educated patient on incentive spirometer, medication, wound care, activities and safety. - Performed pain assessment. Patient stated pain was “not too bad” and 4/10.