Jared Griffin Vsim Documentation Assignment

Answer :

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 assessments showed signs of infection. He had a history of MRSA which was shown when a nasal swab, positive for MRSA, was done during his recent preoperative check. Mr Griffin’s postoperative assessment

sowed no signs of infection. I know this is true because his vital signs showed that his blood oressure, respiratory rate, temperature, pulse all came back within the normal range. Also, his dressing was clean, dry, showed no sign of swelling, redness, or warmth. The patient did not show any signs of infection at this time.

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

Delayed surgical recovery related to infection, ineffective peripheral tissue fusion related to surgery, risk for peripheral neurovascular dysfunction related to surgical procedure, impaired tissue integrity reguarding to wound, impaired physical mobility related to musculosceltal impairment, surgery, prothesis, activity intolerance related to pain and surgical procedure, risk for constipation related 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).

First, I put on a gown and gloves. Then reviewed the patients information, diagnosis, MAR, orders, and the intake and output. The patient’s status: heart rate: 79. Pulse: present. Blood pressure: 135/81 mm Hg. Respiration : 16. Conscious state: Appropriate. SpO2: 97%. Temp: 99 F (37 C). After reviewing the records, I introduced myself and after, identified the patient. Then, I looked for normal breathing. His breathing was 15 breaths per minute, and his chest was moving equally. Now, I attatched the pulse oximeter and checked blood pressure. His blood pressure was 132/80. Then, I checked the radial pulse; it was strong and was 80 per minute. Now, I asked the patient if he had any allergies. He replied that he was allergic to codeine. Then, I checked the temperature and it was normal at 98 F. Now, I educated the patient obout activities, safety, and fall risk. After, I assessed the patient’s dressing and educated him about wound care. Now, I assessed the IV site. The site had no redness, swelling, infiltration, bleeding or drainage. The dressing was dry and intact. Then, I examined the patient’s legs.The right knee was able to bend 75 degrees. There is a dressing covering the skin lesion on lower leg. There is normal elasticityof the skin. His color is mornal, and he is not sweating. Then, I had the patient use an incentive sperometer, and I educated the patient about it. I also edicated the patient about personal protective equipment. Finally, I assessed his pain. I asked if he had any pain, and he replied yes, he was feeling a little more in his knee. I asked him if anything made the pain better, and he saud no, not really. I asked if anything made the pain worse, and he said that it hurts a bit when he bends his knee. I asked him to rate his pain, and he rated it abiut a 2. Lastly, I educated him about the incentive spirometer, and handed off the patient.

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

S- Jared Griffin is a 63 year old African American male who had a right total knee arthroplasty yesterday morning.

B- 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 office during his recent preoperative visit and came back positive for MRSA. Decolonization protocol was initiated prior to his admission for the right total knee arthroplasty. He is currently under contact precautions per hospital policy. He has a history of osteoarthritis & mild hypertension.

A- Mr. Griffin’s vitals have been stable through the night, he has a pain level of 2/10. I assessed his IV and surgical site for infection, and found no signs of redness, swelling, bleeding, or drainage. The dressings are dry, clean, and intact. I also used the incentive spirometer as ordered.

R- Continue to monitor Mr. Griffin’s vital signs and pain level. Administer pain medication prn per physicians order. Continue to assess IV and surgical site and dressings for signs of infection. Encourage continuous use of incentive spirometer. Continue with contact precautions per hospital policy