Surgical Case 1: Marilyn Hughes
Documentation Assignments
1. Document a comprehensive pain assessment for Marilyn Hughes.
Patient began complaining of pain almost immediately upon Pt contact. After completing
baselin
...
Surgical Case 1: Marilyn Hughes
Documentation Assignments
1. Document a comprehensive pain assessment for Marilyn Hughes.
Patient began complaining of pain almost immediately upon Pt contact. After completing
baseline vital signs, a pain assessment was performed, patient rates her pain a 9 out of a
pain scale of 0 to 10 and seems to be significant distress. Assessed patients wound,
cyanosis on the limb with the cast, no pedal pulse present on leg with the cast.
Prolonged capillary refill, dressing seems to tight, and skin is cool and very sweaty.
2. Document Marilyn Hughes’ neurovascular assessment.
Patient neurovascular assessment reveals the most probable cause of her pain. Upon
assessment of her left leg it is noted that the patient has an absent pulse, cyanosis,
significant pain rated at a 9 by patient on a scale of 0 to 10, and decreased motor
function. The patient’s pain is unrelieved by narcotic pain medication and loosening of
the patients dressing. These are significant findings and the provider needs to be
notified immediately.
3. Document the changes in Marilyn Hughes vital signs.
Patient initial vital signs were, RR: 21/min, radial pulse: strong 105/min and regular, BP:
15894 mmHg, temp: 99°F, normal skin turgor, skin is cool and very sweaty. Checked
pedal pulse: strong 105/min and regular, the pulse is absent on the left side.
4. Identify and document key nursing diagnoses for Marilyn Hughes.
Ineffective peripheral tissue perfusion related to weak or absent pulses, evidenced by
compartment syndrome and ischemia.
Acute pain related to patient complaining of pain evidenced by patient rating pain at a 9
from a scale of 0 to 10.
5. Referring to your feedback log, document the nursing care you provided and Marilyn
Hughes’ response to this care.
Feedback Log
0:00 You arrived at the patient's side.
0:00 You introduced yourself.
0:10 Patient status - ECG: Sinus tachycardia. Heart rate: 100. Pulse: Present. Blood pressure:
155/92 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 97%. Temp: 99 F (37 C
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