Documentation Case Study AssignmentBackground Data:
Question Documentation Case Study AssignmentBackground Data:You are the practical nurse working on an acute medical/surgical unit. The unit has 42 beds and is staffed by a RN charge nurse. There are three RNs and 4 RPNs on day shift (0730 to 1930). Each patient has a MRP (Most Responsible Physician) assigned for their overall care.Some patients have consultation from specialists for specific elements of their care. NOTE: Day Shift = 0730hrs-1530hrs.Scenario:Mr. S. is an 84-year-old retired train engineer. Mr. S is active; he walks 2 blocks per day and likes to ride his bicycle in the better weather.He arrived at the emergency department via ambulance after falling on the sidewalk at 1630 yesterday afternoon. He was complaining of right hip pain and X-Ray reviled right hip fracture. He was taken to the O.R. at 2230 last night for a total right hip replacement.Following surgery Mr. S. was admitted to the acute medical surgical unit you work on. He is now 72 hours after the surgery. You are assigned to care for him on the day shift: 0730hrs-1530hrsAt the start of your shift the call bell is constantly ringing from Mr. S’s room. When you enter the room at 0745hr Mr. S is very upset complaining of severe hip pain he rates at “9/10”. Mr. S. is flushed, sweating, and very anxious. He is moving about, moaning constantly, in his bed demanding “I want my pain medication, I can’t stand the pain”. You take a set of vital signs:Vitals: Temperature 37.9 Pulse – 88 bpm Respirations – 26/minBP: 150/90mmHg Sp02: 96% on RA. Pain: 9/10 on a scale of 1 to 10. Region: right hip. Fifteen minutes later you administer Morphine 10 mg S/C for his complaints of pain. Thirty minutes after administering the morphine the assessment is noted as follows: Vitals: Temperature 37.9 Pulse – 90 bpm Respirations – 20/minBP: 140/80 mmHg Sp02: 96% on RA. Pain: 6/10 on a scale of 1 to 10. Region: right hip. Client states ‘My pain is much better now”. Twenty minutes later his breakfast arrives and you assist him into the chair and assist with his meal tray set up. He eats 250 mL cream of wheat, and drinks 125 mL of orange and 250 mL of clear tea. After breakfast you assist him back to bed.At 1030hr you give Mr. S a total bed bath and assist him to brush his teeth.At this time, you notice his right hip dressing has a small amount sanguineous fluid oozing through. At 1130 you notice that he is more restless than usual so you recheck his Mr. S’s vital Signs:· Temperature 39.1 · Pulse 100 bpm · Respirations 32/min · BP 150/90 mmHg· SpO2 – 96% on RA· Pain 7/10At 1150, you reinforce his right hip dressing with an abdominal pad, and give him Tylenol with codeine 30mg, 2 tabs PO.At 1230, you notify the MRP Dr. C. of the client’s fever and increased respiratory rate. Dr. C. orders a chest X-rays and requests that you to continue to monitor the client’s respiratory status. At 1330 vital signs are:· Temperature 390 C· Pulse 92 bpm · Respirations 26/min · BP 140/85 mmHg · SpO2 – 97% RA· Pain 4/10One hour later you reassess the client’s condition and he is comfortable.· Temperature 37.50 C· Pulse 90 bpm · Respirations 24/min · BP 140/85 mmHg · SpO2 – 97% RA· Pain 3/10 Documentation Assignment:1) narrative note regarding the situation above with the assessment and the responses. 2) A DAR note regarding the situation above with the assessment and the responses. Health Science Science Nursing NURS 101 Share QuestionEmailCopy link Comments (0)
