Sara Lin
Documentation Assignments
1.Document your focused pain assessment of Sara Lin.
Pain assessment: preformed vital signs for Sara Lin, BP 136/80, pulse 95, Temp 99 F , SpO2 98%, R 21- equal breathing, skin is normal elasticity, cool, sweaty. Pain level is 6 , on a pain scale of 0-10, pain is sharp in lower quadrants. 2.Document your priorities for care of this patient.
-Check vital signs
-Check incision and dressing
-Asset pain -Edjucate patient about medications, wound care, usage of inactive spirometer, diet, and activity.
-Administer medications as per order.
-position patient in laying position to ace the pain. 3.Document two nursing diagnoses for this patient.
- Acute pain related to d istension of intestinal tissues by inflammation as evidence by r eports of pain.
-Risk of infection related to surgical incision.
4.Document patient education regarding pain management for this patient.
-Patient will take pain medications as needed, without waiting until pain is sever of increasing. Patient will lay at semi Fowler or supine position to ace the pain symptoms. Patient will start walking excessive slowly, to help move the body muscles, reduce gas and help to reduce the abdominal inflammation. Patient will avoid sitting to long in high Fowler position, to prevent pressure on surgical site and the abdomen. From vSim for Nursing | Fundamentals. © Wolters Kluwerhttps://www.coursehero.com/file/41935083/SaraLin-DAodt/This study resource was
shared via CourseHero.com
Documentation Assignments
1.Document your focused pain assessment of Sara Lin.
Pain assessment: preformed vital signs for Sara Lin, BP 136/80, pulse 95, Temp 99 F , SpO2 98%, R 21- equal breathing, skin is normal elasticity, cool, sweaty. Pain level is 6 , on a pain scale of 0-10, pain is sharp in lower quadrants. 2.Document your priorities for care of this patient.
-Check vital signs
-Check incision and dressing
-Asset pain -Edjucate patient about medications, wound care, usage of inactive spirometer, diet, and activity.
-Administer medications as per order.
-position patient in laying position to ace the pain. 3.Document two nursing diagnoses for this patient.
- Acute pain related to d istension of intestinal tissues by inflammation as evidence by r eports of pain.
-Risk of infection related to surgical incision.
4.Document patient education regarding pain management for this patient.
-Patient will take pain medications as needed, without waiting until pain is sever of increasing. Patient will lay at semi Fowler or supine position to ace the pain symptoms. Patient will start walking excessive slowly, to help move the body muscles, reduce gas and help to reduce the abdominal inflammation. Patient will avoid sitting to long in high Fowler position, to prevent pressure on surgical site and the abdomen. From vSim for Nursing | Fundamentals. © Wolters Kluwerhttps://www.coursehero.com/file/41935083/SaraLin-DAodt/This study resource was
shared via CourseHero.com
