Documentation Assignments
1. Document your finding related to Mr. Griffin's preoperative and postoperative assessment findings regarding the presence of an infection.
During the preoperative assessment a nasal swab was
...
Documentation Assignments
1. Document your finding related to Mr. Griffin's preoperative and postoperative assessment findings regarding the presence of an infection.
During the preoperative assessment a nasal swab was taken and was positive for MRSA. Mr. Griffins postoperative assessment did not show any signs of infection and the vital signs and temperature were normal with no sign of fever.
2. Identify and document key nursing diagnoses for Mr. Griffin regarding current condition. Activity Intolerance related to undergoing postoperative care of TKA surgery due to Mr. Griffin experiencing decreased ROM related to being postoperative as well as his age which is 63 years old.
Delayed surgical recovery due to Mr. Griffin being positive for MRSA. Acute pain related to inflammation and injury in the surgical area.
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).
First I reviewed the patient record and performed hand hygiene. I reviewed the necessary infection precaution for MRSA and put on my gown and gloves. I introduced myself to Mr. Griffin and verified his full name and DOB. Mr Griffin confirmed his allergy to codeine. Upon taking vitals, Mr. Griffin was fully compliant. Respirations- 15bpm. Pulse- radial- 80/min strong and regular; BP- 137/81 mm/Hg. Otic Temperature was 98 degrees
F. SpO2- 97%. Cap refull- less than 2 seconds. 2 out of 10 pain. Skin is dry, warm and elasticity is normal. Color of skin is normal and dressing on skin lesion is clean, dry and intact on lower leg. I asked Mr. Griffin if he was in pain and he stated “it hurts a little when I bend the knee”. Mr Griffin declined pain medication. I assessed the IV and there was no redness, swelling, infiltration, bleeding or drainage. I educated Mr Griffin on activities, safety, fall risk, personal protective equipment, incentive spirometer and wound care.
4. Document your handoff report in the SBAR format to communicate Mr. Griffin's future needs.
Situation: Hared Griffin is a 63 year old African American male who had a right total knee arthroplasty (TKA) yesterday morning.
Background: Mr. Griffin has a history of MRSA, which was diagnosed 3 years ago when he had surgery for a hammertoe. A nasal swab was done in the office during his recent
preoperative check that came back positive for MRSA. Decolonization protocol was initiated prior to the admission for the total knee procedure and he is currently under contact precautions per hospital policy. He has a history of osteoarthritis and mild hypertension.
Assessment: Mr. Griffin is afebrile with a temp of 37.2 °C (99.8 °F), and vital signs have been stable during the night. Pain level has been at a 2–3. He has dangled his feet off the side of the bed and will have physical therapy in his room at 1000. He has been able to bend his knee to a 75-degree angle and the goal is 90 degrees. The surgeon changed Mr. Griffin’s dressing, and discontinued the drain and IV fluids, at 0700 on his morning round. His labs just came up, but I haven't had a chance to look at them yet.
Recommendation: Please carefully watch over Mr. Griffins pain level and vital signs. Look for signs of infections and assess the dressing regularly. Continue with contact precautions and consider a team inclusive of infectious disease specialist, home nurse and case manager upon discharge.
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