Questions VSIM

Question 1 - Performed a pain assessment for patient - took patient’s vital signs - BP: 136/80 - monitor pulse: 98 bpm - pedal pulse: 100 bpm - temp: 99 F, - respirations: 21, - SpO2: 98%. - 0-10 pain scale: 6. - Patient stated that: “The pain is sharp on my side. My belly hurts and kind of throbs.” Question 2 - Take vital signs and assess the patient's pain. - Administer pain medication in accordance with the physician's orders. - Perform assessment of all patient’s incisions and dressings. - Provide the patient with important education about the incentive spirometer, wound care, signs of infection, activity restrictions, and pain/antibiotics. Question 3 - Acute pain: surgical incision. This is evidenced by the patient’s statement: “The pain is sharp on my side. My belly hurts and kind of throbs.” -Willingness to learn, evidenced by the patient's statement: “I want to know how much I can do at home.” Question 4 - The patient was provided important information about wound care. - The patient was also encouraged to immediately contact the physician in the event of excessive drainage, swelling, and/or redness surrounding the incision. - The patient was educated on safety and activities and was cautioned to avoid using heavy machinery or operating a vehicle while taking their pain medication. - Patient was provided important information about medication and was directed to take medications as advised by their physician. Question 5 - Properly introduced self to patient, immediately washed hands upon entering the room, identified patient using 2 separate identifiers, put on gloves, asked patient if she had allergies and verified that she had none. - Performed pain assessment. The patient reported pain from 0-10 to be: 6/10. - Took patient vitals. - BP: 136/80 - monitor pulse: 98 bpm - pedal pulse: 100 bpm - temp: 99 F - respirations: 21 - SpO2: 98% - Compared medication label with MAR to ensure no mistakes were made and gave 5 mg oxycodone orally as prescribed by doctor order. - Performed another pain assessment, and the patient stated pain was “pretty bad” and reported a score of 5/10. - Auscultated lungs; breath sounds were clear and equal with both lungs. - Auscultated heart; heart sounds were regular and had no murmurs. - Auscultated abdomen area; normal, typical bowel sounds in all quadrants. - Respirations were observed and recorded to be 21 breaths per min. The patient’s chest was observed to move equally. - Performed assessment of both pedal and radial pulses; her pulses were strong, 100/min and regular. - Assessed IV site, no redness, swelling, infiltration, bleeding, or drainage. - Assessed patient’s abdominal incision. - The patient utilized an incentive spirometer. - Compared medication label to MAR to ensure no mistakes were made and gave 325 mg acetaminophen orally as prescribed by doctor order. - Compared medication label to MAR, gave 500 mg levofloxacin orally as prescribed. - Performed pain assessment. Patient stated pain was still 5/10. - Provided the patient with important information about her incentive spirometer, medications, wound care, as well as activities and safety. - Performed a final pain assessment. Patient stated pain was “not too bad” and 4/10 Guided questions Sara Lin 1. The priority problem for this patient was her intense pain. 2. Her education plan should encourage her to immediately contact her nurse or healthcare provider to assist her whenever she starts feeling pain to ensure that they address/stop the pain before it gets too bad. 3. Her education plan should inform the patient of the importance and benefits of using mild soap and gentle washing techniques on her incision. It should also inform her to cover the incision with dry dressings after, and to immediately contact her provider in the event of any observable swelling, redness, odorous secretions, warmth, or if pain occurs. 4. It should include that antibiotics should always be taken with water, and should be taken at the same time each day with no variation. It should inform her that taking Levofloxacin with food is optional; it can be taken with or without. It should also inform her that when taking Levofloxacin oral solution, make sure to take it on an empty stomach: 1 hour before or 2 hours after a meal. 5. I believe that the information that I gained here would be very helpful when dealing with any future patient that is suffering from acute appendicitis. Every patient is different, but I would at least be able to determine what some general priority problems are. I would also be able to offer some important information on incision care.