Surgical Case 1: Marilyn Hughes Documentation and Guided Questions

© Wolters Kluwer Health | Lippincott Williams & Wilkins Surgical Case 1: Marilyn Hughes Documentation Assignments 1. Document a comprehensive pain assessment for Marilyn Hughes. - Upon the pain assessment, patient reported 8/10 an hour after receiving morphine on the left leg and that it hurt each time it was being touched. She reported the pain to be throbbing due to the dressing being too tight on the lower extremity, nothing was making it feel better. 2. Document Marilyn Hughes’ neurovascular assessment. - the neurovascular exam was within normal expectations except the fact that there was no pulse on the left lower extremity. 3. Document the changes in Marilyn Hughes vital signs. - before beginning the assessment, the vital signs were BP 130/82, HR 88, RR 16. Once the assessment began and there was a check up on the vital signs, there was increasing results on BP 158/94, RR 21, 02 98, Temp 99, HR 110. 4. Identify and document key nursing diagnoses for Marilyn Hughes. - Ineffective peripheral tissue perfu sion related to increased pressure on the lower left extremity as evidenced by lack of left pedal pulse, reported pain, cool to touch skin, tenderness and slow capillary refill. - acute pain related to post -operative ORIF as evidenced by increased vital s igns and increased lower extremity pain. - acute pain related to ineffective medication as evidenced by increasing pain after administration, sweating and increasing heart rate and blood pressure. 5. Referring to your feedback log, document the nursing care you provided and Marilyn Hughes’ response to this care. - Entered the patient room and performed hand hygiene and identified the patient by two identif iers. Pain assessment was performed, in which resulted in 8/10 on the lower left extremity, throbbin g pain with no radiation to other areas of the body, it started after the surgery was performed and nothing is making it better. Pain worsens when touched . Patient was then educated to what the check -up was about, moved on to the assess ment the vital signs . Checked for the pedal pulses and did the neurovascular assessment , cyanosis and cool to touch on the left lower extremity with the inability to move toes, there was also no reported pedal pulse . Upon assessment of the dressing, it was too tight on the ex tremity therefore it was loosened it and lowered her leg to heart level. Provided education to the patient about the actions just performed and then reassessed the vital signs in which the heart rate had begun to decrease.