Surgical Case 1: Marilyn Hughes
Documentation Assignments
1. Document a comprehensive pain assessment for Marilyn Hughes.
Marilyn’s pain was high when she scaled it at an 8. She mentioned that her bandages felt
too tight. I loosened her bandages and lowered her leg to heart level and assessed her
pain again, this time it was lowered at a 5.
2. Document Marilyn Hughes’ neurovascular assessment.
My initial assessment of her pedal pulses were bounding in the right leg 105bpm and
absent in the left leg. After my interventions the pulse went down to 95bpm in the right
leg but was still absent in the left (affected) leg.
3. Document the changes in Marilyn Hughes vital signs.
Ms. Hughes vital signs were stable post surgery then increased as her pain increased.
After interventions it went back down into normal range.
4. Identify and document key nursing diagnoses for Marilyn Hughes.
Impaired mobility related to bone fracture
Risk for falls related to impaired mobility
Risk for infection related to surgical incision
Risk for peripheral neurovascular dysfunction related to reduction of blood flow
5. Referring to your feedback log, document the nursing care you provided and Marilyn
Hughes’ response to this care.
I took Ms. Hughes vital signs- her response was okay and her vitals were within normal
range
I loosened her restrictive bandages and she responded well
I lowered her affected leg and she responded well to that as well.
I preformed mt safety measures by confirming it was the right patient and getting
consent also checking for any allergies. I left the patient in bed and resting prior to hand
off.
© Wolters Kluwer Health | Lippincott Williams & Wilkins
Documentation Assignments
1. Document a comprehensive pain assessment for Marilyn Hughes.
Marilyn’s pain was high when she scaled it at an 8. She mentioned that her bandages felt
too tight. I loosened her bandages and lowered her leg to heart level and assessed her
pain again, this time it was lowered at a 5.
2. Document Marilyn Hughes’ neurovascular assessment.
My initial assessment of her pedal pulses were bounding in the right leg 105bpm and
absent in the left leg. After my interventions the pulse went down to 95bpm in the right
leg but was still absent in the left (affected) leg.
3. Document the changes in Marilyn Hughes vital signs.
Ms. Hughes vital signs were stable post surgery then increased as her pain increased.
After interventions it went back down into normal range.
4. Identify and document key nursing diagnoses for Marilyn Hughes.
Impaired mobility related to bone fracture
Risk for falls related to impaired mobility
Risk for infection related to surgical incision
Risk for peripheral neurovascular dysfunction related to reduction of blood flow
5. Referring to your feedback log, document the nursing care you provided and Marilyn
Hughes’ response to this care.
I took Ms. Hughes vital signs- her response was okay and her vitals were within normal
range
I loosened her restrictive bandages and she responded well
I lowered her affected leg and she responded well to that as well.
I preformed mt safety measures by confirming it was the right patient and getting
consent also checking for any allergies. I left the patient in bed and resting prior to hand
off.
© Wolters Kluwer Health | Lippincott Williams & Wilkins
