SaraLin_DA,WELL EXPLAINED WITH VERIFIED ANSWERS.

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 distension of intestinal tissues by inflammation as evidence by reports 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. 5. Referring to your feedback log, document the nursing care you provided to Sara Lin and her response. During my shift I provided the following care to Sara Lin: I Checked her vital signs, her surgical incision and the wound dressing. I questioned the patient about her pain and how she feels, preformed pain assessment. After checking doctors order I educated Sara about her oral medications and administered those medication to her. Another important step was education her about wound care, the usage of inactive spirometer, her diet, and post surgical physical activity. Patient preformed usage of inactive spirometer , and demonstrated that she understood the education that was provided. Patient asked questions related to her rehabilitation. Before leaving the room I positioned the patient in laying position to ace the pain