Jared Griffin
Documentation Assignments
1. Document your finding related to Mr. Griffin's preoperative and postoperative
assessment findings regarding the presence of an infection.
Preop: MRSA positive; contact precautions
Post Op:
Pedal Pulse: Strong 80 beast per min TemP: 98F HR: 80 BP: 136/81 RR: 15 SpO2:
97% Pain: 2 out of 10
No drainage or inflammation noted at surgical site
2. Identify and document key nursing diagnoses for Mr. Griffin regarding current condition.
Delayed surgical recovery related to history MRSA infection as evidence by positive
MRSA result
Activity tolerance related to total knee replacement evidence bend knee to 75 degree
angle
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).
Reviewed patient information, log, diagnostics, clinical obserbations, MAR, orders,
intake and out. Noted contact precautions; applied by gloves and grown due to positive
MRSA. Vital Signs: Pedal Pulse: Strong 80 beast per min TemP: 98F HR: 80 BP:
136/81 RR: 15 SpO2: 97% Pain: 2 out of 10 No abnormal findings observed w/ head
to toe assessment. No s/s of infection observed. Educated patient on activities, safety,
fall risk, improving venous return, incentive spirometer, wound care, and personal
protective equipment. Incentive spirometer X1.
4. Document your handoff report in the SBAR format to communicate Mr. Griffin's future
needs.
Situation: Jared Griffin is a 63 year old African American male who had a right total knee
arthroplasty yesterday morning. MRSA positive, contact precuations in place
Backgroud: Mr. Griffin has history of MRSA, osteoarthritis, and mild hypertension
Assessment: A&OX4, elevated BP, measures pain 2 out of 10, ROM is 70%, no s/s of
infection at surgical site.
Recommendation: Monitor BP, pain level, and vital signs. Assist with ambulation. Check
for s/s of infection and check dressings. Continue contact precautions.
vSim for Nursing | Fundamentals. © Wolters Kluwer
Documentation Assignments
1. Document your finding related to Mr. Griffin's preoperative and postoperative
assessment findings regarding the presence of an infection.
Preop: MRSA positive; contact precautions
Post Op:
Pedal Pulse: Strong 80 beast per min TemP: 98F HR: 80 BP: 136/81 RR: 15 SpO2:
97% Pain: 2 out of 10
No drainage or inflammation noted at surgical site
2. Identify and document key nursing diagnoses for Mr. Griffin regarding current condition.
Delayed surgical recovery related to history MRSA infection as evidence by positive
MRSA result
Activity tolerance related to total knee replacement evidence bend knee to 75 degree
angle
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).
Reviewed patient information, log, diagnostics, clinical obserbations, MAR, orders,
intake and out. Noted contact precautions; applied by gloves and grown due to positive
MRSA. Vital Signs: Pedal Pulse: Strong 80 beast per min TemP: 98F HR: 80 BP:
136/81 RR: 15 SpO2: 97% Pain: 2 out of 10 No abnormal findings observed w/ head
to toe assessment. No s/s of infection observed. Educated patient on activities, safety,
fall risk, improving venous return, incentive spirometer, wound care, and personal
protective equipment. Incentive spirometer X1.
4. Document your handoff report in the SBAR format to communicate Mr. Griffin's future
needs.
Situation: Jared Griffin is a 63 year old African American male who had a right total knee
arthroplasty yesterday morning. MRSA positive, contact precuations in place
Backgroud: Mr. Griffin has history of MRSA, osteoarthritis, and mild hypertension
Assessment: A&OX4, elevated BP, measures pain 2 out of 10, ROM is 70%, no s/s of
infection at surgical site.
Recommendation: Monitor BP, pain level, and vital signs. Assist with ambulation. Check
for s/s of infection and check dressings. Continue contact precautions.
vSim for Nursing | Fundamentals. © Wolters Kluwer
