Josephine Morrow Documentation Assignments (answered)
100% score
Documentation Assignments
1. Document the findings of a focused skin assessment of Ms. Morrow, including any
findings that identify the presence of chronic venous insufficiency.
There is a dressing covering the skin lesion on the lower leg. When I assessed the
ulcer on the lower leg, it was shallow, 1 inch in width and was mostly pink to red
with no signs of necrosis or infection.
2. Document any abnormal laboratory results that are associated with the presence or status
of Ms. Morrow's stasis ulcer.
A proper albumin level is helpful when a patient has a wound. Albumin is a
protein that acts as a building block for cells and tissues. It is produced by the
liver. Protein in the body helps with the wound healing process. For Ms.
Morrow’s case, her albumin levels were slightly below level at a 3.4 g/dL.
Prealbumin is another type of protein produced by the liver but it is a better
indicator of acute nutritional changes. Her prealbumin levels were significantly
low at a 14.7mg/dL level. The lower the prealbumin the greater risk of mortality.
It helps in the healing process of wounds because it carries vitamin A throughout
the body as well.
3. Record the results of Ms. Morrow's Braden Scale assessment.
Her braden scale is 16 and her skin is intact except for the venous stasis ulcer on
the right medial malleoulus. A 16 on the braden scale means that she is at a low
risk.
4. Document the characteristics of Ms. Morrow's venous stasis ulcer.
The ulcer is shallow, 1 inch in width, looking mostly pink to red, with no signs of
necrosis or infection.
5. Document the dressing change and irrigation of Ms. Morrow’s wound.
I uncovered the would by removing the old dressing and assessed the wound. The
wound showed no signs of infection. I removed my gloves and washed my hands.
I applied new gloves and then irrigated the wound with normal saline to remove
any secretions that were in the wound. Then I applied a clean new dressing to the
ulcer.
6. In the chart, record patient education on ways to promote venous return.
I educated the patient about wound care and how to improve venous return. Some
ways to improve venous return could be as simple as walking as much as possible
every day. Any type of movement will get the blood regulating through the body
amurimi
100% score
Documentation Assignments
1. Document the findings of a focused skin assessment of Ms. Morrow, including any
findings that identify the presence of chronic venous insufficiency.
There is a dressing covering the skin lesion on the lower leg. When I assessed the
ulcer on the lower leg, it was shallow, 1 inch in width and was mostly pink to red
with no signs of necrosis or infection.
2. Document any abnormal laboratory results that are associated with the presence or status
of Ms. Morrow's stasis ulcer.
A proper albumin level is helpful when a patient has a wound. Albumin is a
protein that acts as a building block for cells and tissues. It is produced by the
liver. Protein in the body helps with the wound healing process. For Ms.
Morrow’s case, her albumin levels were slightly below level at a 3.4 g/dL.
Prealbumin is another type of protein produced by the liver but it is a better
indicator of acute nutritional changes. Her prealbumin levels were significantly
low at a 14.7mg/dL level. The lower the prealbumin the greater risk of mortality.
It helps in the healing process of wounds because it carries vitamin A throughout
the body as well.
3. Record the results of Ms. Morrow's Braden Scale assessment.
Her braden scale is 16 and her skin is intact except for the venous stasis ulcer on
the right medial malleoulus. A 16 on the braden scale means that she is at a low
risk.
4. Document the characteristics of Ms. Morrow's venous stasis ulcer.
The ulcer is shallow, 1 inch in width, looking mostly pink to red, with no signs of
necrosis or infection.
5. Document the dressing change and irrigation of Ms. Morrow’s wound.
I uncovered the would by removing the old dressing and assessed the wound. The
wound showed no signs of infection. I removed my gloves and washed my hands.
I applied new gloves and then irrigated the wound with normal saline to remove
any secretions that were in the wound. Then I applied a clean new dressing to the
ulcer.
6. In the chart, record patient education on ways to promote venous return.
I educated the patient about wound care and how to improve venous return. Some
ways to improve venous return could be as simple as walking as much as possible
every day. Any type of movement will get the blood regulating through the body
amurimi
