vSim Health Assessment Case 7: Jared Griffin

vSim Health Assessment Case 7: Jared Griffin Documentation Assignments 1. Document your findings and Mr. Griffin's reactions related to the focused assessment regarding his cardiovascular status. I explained to patient that I was going to perform a focused cardiovascular assessment. Patient was receptive but did not seem to understand what it completely entailed. I continued to explain that it involved assessing vital signs, determining whether or not patient experiences any chest pain, assessing blood circulation, and listening to heart sounds. I assessed the heart and the extremities, collected subjective data such as leg pain, chest pain, dizziness, and dyspnea. I assessed the neck and skin for vein distention, there was none and color and temp was normal. I auscultated the heart. Pedal pulses were 95, 2+ but irregular. Patient said that he did not have any chest pain. 2. Referring to your feedback log, document all nursing care provided and Mr. Griffin's response to this care. I checked the patients vital signes, attatched a pulse oximeter, looked for normal breathing, check capillary refill, inspected the skin, IV site, and nails- no abnormal findings. The client said he did not have any chest pain when asked. The lung sounds were clear. I educated the patient about activities, safety, and fall risks. Client said that he did not have any trouble breathing “My breathing is fine”. I assessed the patients feet, skin, pedal pulses were strong +2. Educated him about the plan of care, and encouraged coughing. Also auscultated the abdomen- normal sounds. 3. Document all patient teaching regarding assessments and safety issues provided to Mr. Griffin, and his response to the teaching. I educated the patient about activities, safety, and fall risks. Educated him about the plan of care, and encouraged coughing. Asked patient about pain: Patient replied yes to pain in right knee; pain is constant and sore; 3/10 on pain scale, painkillers help. Asked patient about allergies: “I am allergic to codeine. I get a rash”. Patient was very receptive and handled the assessment well with no issues. Educated patient on what a focused cardiovascular assessment entailed and later explained the plan of care as it had changed after physician ordered a 12-lead EKG. I explained that this was because we heard an irregular rhythm of the heart and wanted to better understand what was going on. Patient was receptive and seemed to understand. 4. Document your handoff report in the SBAR format to communicate Mr. Griffin's future needs. Hello, this is Nurse Jen caring for patient Jared Griffin in room 305. He is 53 years old and just had a total knee arthroplasty, he reported not feeling w