Preoperative and postoperative assessment

Jared Griffin vsim stimulation documentation assignment

1. Document your finding related to Mr. Griffin’s preoperative and postoperative assessment findings regarding the presence of an infection

Mr. Griffin’s pre-operative examinations revealed evidence of infection. He had a history of MRSA, which was revealed when a nasal swab was positive for MRSA during a recent preoperative examination. Mr Griffin’s postoperative examination revealed no symptoms of infection. I know this since his vital signs showed that his blood pressure, respiration rate, temperature, and pulse were all within normal limits. In addition, his bandage appeared clean and dry, with no signs of swelling, redness, or warmth. At this time, the patient showed no indications of infection.

2. Identify and document key nursing diagnoses for Mr. Griffin regarding current condition

Delayed surgical recovery due to infection, ineffective peripheral tissue fusion due to surgery, risk of peripheral neurovascular dysfunction due to surgery, impaired tissue integrity due to wound, impaired physical mobility due to musculoskeletal impairment, surgery, prothesis, activity intolerance due to pain and surgical procedure, risk of constipation due to decreased activity, anastesia, pain medication

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)

I started by putting on a gown and gloves. The patient’s information, diagnosis, MAR, orders, and intake and output were then examined. The patient’s condition: 79 beats per minute. The pulse is present. 135/81 mm Hg blood pressure 16. Respiration Appropriate conscious state. SpO2 level: 97 percent. 99 degrees Fahrenheit (37 C). I introduced myself and then identified the patient after studying the documents. Then I checked for regular breathing patterns. His breathing rate was 15 breaths per minute, and his chest moved evenly. I took out the pulse oximeter and checked my blood pressure. He had a blood pressure of 132/80. Then I tested the radial pulse, which was robust and measured 80 beats per minute. Now I questioned the patient if he was allergic to anything. He said he was allergic to codeine. Then I checked the temperature, which was normal at 98 degrees Fahrenheit. Now, I’ve taught the patient about activities, safety, and the dangers of falling. Following that, I evaluated the patient’s dressing and briefed him on wound care. Now I’m evaluating the IV location. There was no redness, swelling, infiltration, hemorrhage, or drainage at the location. The dressing was dry and unbroken. Then I looked at the patient’s legs. The right knee could bend 75 degrees. A dressing covers the skin lesion on the lower thigh. The skin has normal elasticity. He has a mornal complexion and is not sweating. The patient was then asked to utilize an incentive sperometer, and I educated him about it. I also educated the patient on the need of wearing personal protection equipment. Finally, I assessed his discomfort. I asked whether he was in any discomfort, and he said he was, with a little more pain in his knee. I asked him whether anything helped with the pain, and he said no, not really. I inquired if anything made the discomfort worse, and he said that bending his knee hurts a little. I asked him to rate his pain, and he gave it a rating of about a 2. Finally, I explained the incentive spirometer to him and handed over the patient.

4.Document your handoff report in the SBAR format to communicate Mr. Griffin’s future needs.

S- Jared Griffin, a 63-year-old African-American man, underwent a right total knee arthroplasty yesterday morning. B- Mr. Griffin has a history of MRSA, which was discovered three years ago during surgery for a hammertoe. During his recent preoperative appointment, a nose swab was performed in the office and tested positive for MRSA. Prior to his admittance for right complete knee arthroplasty, a decolonization program was commenced. As per hospital regulation, he is currently under contact precautions. He has had osteoarthritis and moderate hypertension in the past.
A- Mr. Griffin’s vitals have been stable all night, and he has a pain level of 2/10. I examined his IV and surgical site for evidence of infection and found no redness, swelling, bleeding, or drainage. The dressings are dry, clean, and in good condition. I also utilized the ordered incentive spirometer.
R- Keep an eye on Mr. Griffin’s vital signs and pain level. In accordance with the doctor’s orders, administer pain medicine on a daily basis. Continue to look for symptoms of infection in the IV, surgery site, and dressings. Encourage the usage of the incentive spirometer on a regular basis. Maintain contact precautions in accordance with hospital policy.

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