Jared Griffin - Documentation Assignments

Jared Griffin Documentation Assignments 1. Document your finding related to Mr. Griffin's preoperative and postoperative assessment findings regarding the presence of an infection. Preoperative finds: Mr. Griffin has shown signs of an infection, a nasal swab test was done resulting on positive result for MRSA. Postoperative finds: Mr. Griffin has shown no signs of an infection, based on the vital signs, his temperature is in a normal range. 2. Identify and document key nursing diagnoses for Mr. Griffin regarding current condition. Mr. Griffin nursing diagnoses would be delayed surgical recovery related to MRSA. Also, another nursing diagnosis is activity intolerance related to undergoing postoperative care of total knee arthroplasty (TKA) surgery. Mr. Griffin is experiencing decreased ROM related to being postoperative. Last nursing intervention that I identify is acute pain related to inflammation/ injury in surgery area. 3. Referring to your feedback log, document all nursing care provided as well as Mr. Griffin's response to this care, including responses related to infection control and the use of personal protective equipment (PPE). Mr. Griffin is a 63-year-old male. I looked over my patient chart, washed my hands, put on gloves and gown, introduced myself, verified name and DOB, he responded appropriately. Has a codeine allergy. Respirations-15/min. Pulse- radial, 80/min, strong, regular; pedal- 80/min, strong, regular. BP-137/81 mm/Hg. Temp- 98 degrees F. SpO2: 97%. Cap. Refill- less than two seconds. 2/10 pain in knee. Skin is dry, warm, elasticity is normal, color is normal, with a dressing on the skin lesion on lower leg. I assessed patient’s dressing to see if there were any signs of infection, the dressing was dry and clean. Mr. Griffin willingly used the incentive spirometer that was ordered. Assessed the patient’s IV, there was no redness, swelling, infiltration, bleeding, or drainage. The dressing was intact and dry. I then took the time to educate the patient regarding activities, safety, fall risk, personal protective equipment, incentive spirometer, and wound care. 4. Document your handoff report in the SBAR format to communicate Mr. Griffin's future needs. Situation: Jared Griffin is a 63-year-old African American male who had a right total knee arthroplasty (TKA) yesterday morning. Background: Mr. Griffin has a history of MRSA, which was diagnosed 3 years ago when he had surgery for a hammertoe. A nasal swab was done in the office during his recent preoperative check that came back positive for MRSA. Mr. Griffin is currently under contact precautions per hospital policy. He has a history of osteoarthritis and mild hypertension. Assessment: Mr. Griffin’s vital signs have been stable, 2 pain level, checked dressings and there are no signs of infection. Mr. Griffin has an IV hook up and a dressing on right lower leg from surgery. Has kept up with incentive spirometer. Recommendation: Keep checking on Mr. Griffin’s pain level and vital signs and keep assess for signs of infection. Continue with contact precautions. Opening Questions How did the simulated experience of Jared Griffin’s case make you feel? I was comfortable doing my task with Mr. Griffin’s simulation. Talk about what went well in the scenario. This simulation was very smooth, I was confident during the whole simulation. I did check his dressing, IV, educated about wound care and the importance of having him to use the incentive spirometer. Reflecting on Jared Griffin’s case, were there any actions you would do differently if you were to repeat this scenario? If so, how would your patient care change? To be honest o would not do anything different I was very happy if myself. Scenario Analysis Questions EBP/S What priority problem(s) did you identify for Jared Griffin? Managing his MRSA is a priority problem, and postop care for his TKA. EBP/S What potential problems could arise from improper infection control practices? If the staff does not wear the proper safety equipment, they can spread the infection to other patient and staff member. EBP Discuss the relationship between the spread of hospital-acquired infections (HAIs) and proper infection control. With the proper infection control being utilized, the risk of HAI’s is decreased. PCC/T &C Discuss the importance of patient education on proper infection control practices. It is important to educate our patient on proper infection control practices, so, we can avoid spread infection. T&C What other interprofessional team members should be involved in Jared Griffin’s care? Yes, a good care plan will involve a team working together. Nurses to change dressings and monitor patient vitals, give medication. PT and OT will help the patient with his post-op rehabilitation the Tech will help the patent to ambulate as well other task to help the patient and the whole team will watch out for fall risks. Concluding Questions Describe how you would apply the knowledge and skills that you obtained in Jared Griffin’s case to an actual patient care situation. I learn the importance of PPE as well checking patient IV, dressing educating my patient about wound care.