Jared Griffin Documentation Assignments

1. Document your finding related to Mr. Griffin's preoperative and postoperative assessment findings regarding the presence of an infection. o Mr Griffen has a current history of MRSA. His vital signs have been stable, and pain is 2 on a scale of 1-10. His wound was assessed and is normal with no signs of infection, dressing is clean, dry and intact. 2. Identify and document key nursing diagnoses for Mr. Griffin regarding current condition. o Risk for infection r/t invasive procedure, risk for falls r/t patient reporting soreness in the knee. 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). o After introducing myself and identifying the patient, his vitals, respirations, temperature, and pulses were assessed and I attached a pulse oximeter. I asked the patient if he had any pain, which he responded “Yes, I am feeling a little sore in my knee.” I examined his legs, assessed his dressing and IV site, which he was okay with. I had the patient use an incentive spirometer and educated him that it will help his breathing. I educated him about wound care, which he appreciated because he didn’t know how to treat his wound at home. I also educated him about personal protective equiptment, which he was eager to understand the specifics.