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A Complete Solution on vSim for Nursing | Medical-Surgical

SURGICAL SCENARIOS FOR MARILYN HUGHES

1. Document a comprehensive pain assessment for Marilyn Hughes.

2. Document Marilyn Hughes’ neurovascular assessment.

3. Document the changes in Marilyn Hughes vital signs.

4. Identify and document key nursing diagnoses for Marilyn Hughes.

5. Referring to your feedback log, document the nursing care you provided and Marilyn Hughes’ response to this care.

ANSWER

 1. Document a comprehensive pain assessment for Marilyn Hughes.

I asked her where her pain was located, what kind of pain she was having,

2. Document Marilyn Hughes’ neurovascular assessment.

She said her whole left leg felt numb, and was not able to move or feel her toes on her left side; there was no pulse present on the left foot.

3. Document the changes in Marilyn Hughes vital signs.

Her blood pressure was initially high due to the pain she was having as well as her heart rate . Both resolved, as her pain issue was resolve, both got lowered.

4. Identify and document key nursing diagnoses for Marilyn Hughes.

Acute pain and ineffective tissue perfusion

5. Referring to your feedback log, document the nursing care you provided and Marilyn Hughes’ response to this care.

-I washed your hands.

-I identified the patient.

-I provided patient education.

-I asked the patient if she had any pain. She replied: ‘Yes! Ahh…

-I asked the patient if anything made the pain better. She replied: ‘No. Please give me something for the pain!’

-I asked the patient if anything made the pain worse. She replied: ‘It gets worse when somebody touches my leg.’

-I asked the patient if she could describe her pain. She replied: ‘It feels like the bandage is too tight.’

-I asked the patient where the pain was located. She replied: ‘It’s in my left leg.’

-I asked the patient if the pain went anywhere. She replied: ‘No, not really.’

-I asked: How bad is the pain? She replied: ‘It’s really bad, about 7.’

-I asked the patient how long she had pain for. She replied: ‘Since I got back from surgery…’

-I asked the patient if the pain was better after the medication. She replied: ‘No, it’s actually worse.’

-I examined the patient’s legs. The lower left leg looks cyanotic. The dressing seems really tight. There is prolonged capillary refill in the toes on the left side.

-I listened to the lungs of the patient. The breath sounds are normal.

-I listened to the heart of the patient. There were only normal heart sounds. This is reasonable.

-I looked for normal breathing. She is breathing at 21 breaths per minute. The chest is moving normally on both sides.

-I attached the pulse oximeter. It is a good idea to monitor the saturation and pulse here. This will allow you to reassess the patient continuously.

-I checked the radial pulse. The pulse is strong, 100 per minute and regular

-I measured the blood pressure at 160/96 mm Hg. It is appropriate to monitor the patient by measuring the blood pressure.

-I checked the temperature at the mouth. The temperature was 99 F (37 C).

I attached the automatic noninvasive blood pressure (NIBP) measurement cuff. This will allow you to reassess the patient continuously.

-I assessed the patient’s IV. The site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact. This is correct. Assessing any IVs the patient has is always important.

-I checked the pedal pulse. The pulse is strong, 100 per minute and regular. The pulse is absent on the left side, though. Correct. This is part of a neurovascular assessment when compartment syndrome is suspected.

-I checked the radial pulse. The pulse is strong, 100 per minute and regular.

-I checked the carotid pulse. The pulse is strong, 100 per minute and regular.

-I checked the temperature at the mouth. The temperature was 99 F (37 C).

-I phoned the provider in order to discuss the patient.

-I checked the carotid pulse. The pulse is strong, 100 per minute and regular.

-I checked the radial pulse. The pulse is strong, 100 per minute and regular.

-I checked the pedal pulse. The pulse is strong, 100 per minute and regular. The pulse is absent on the left side, though.

-I assessed the patient’s dressing. This is correct. Assessing any dressings the patient has is always important.

-I loosened the restrictive dressing. This is correct as it improves arterial perfusion.

You assessed the patient’s IV. The site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact. If you are in doubt, it is always a good idea to reassess any IVs the patient has.

-I assessed the patient’s dressing. If you are in doubt, it is always a good idea to reassess any dressing the patient has.

-I assessed the patient’s dressing. If you are in doubt, it is always a good idea to reassess any dressing the patient has.

-I assessed the patient’s IV. The site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact. If you are in doubt, it is always a good idea to reassess any IVs the patient has.

-I asked the patient if she could move her toes. She replied: ‘No. I don’t think so.’

-I phoned the provider in order to discuss the patient.

-A patient handoff was performed.

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