Download NUR 4130 MARILYN HUGHES WORKSHEET NEW and more Exercises Nursing in PDF only on Docsity!
CONCEPT MAP WORKSHEET
DESCRIBE DISEASE PROCESS AFFECTING PATIENT
(INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
DIAGNOSTIC TESTS
(REASON FOR TEST AND RESULTS)
PATIENT INFORMATION
ANTICIPATED PHYSICAL FINDINGS
ANTICIPATED NURSING INTERVENTIONS
Fractures of the tibia and fibula often occur in association with each other and tend
to result from a direct blow, falls with the foot in a flexed position, or a violent
twisting motion.
splint: device designed specifically to support and immobilize a body part in a desired
position
Compartment syndrome,
cyanosis,
Pale, pallor,
Decreased pedal pulses,
Swelling, edema
N/A
Marilyn Hughes, 45
year old female,
suffered a left mid-
shaft tibia-fibula
fracture when she
slipped on icy stairs this
morning
taken to surgery for an
open reduction with
internal fixation (ORIF).
Promote circulation
Assess wound
Assess post operative dressing
Assess vital signs
vSim ISBAR ACTIVITY
STUDENT WORKSHEET
INTRODUCTION
Karen Brito RN , Med Surge Unit
Your name, position (RN), unit you are
working on
SITUATION
Marilyn Hughes, 45 year old female, suffered a left mid-shaft tibia-
fibula fracture
Patient’s name, age, specific reason for visit
BACKGROUND
Primary diagnosis is compartment syndrome after the surgery , date of
admission 4/12/2020, current orders are morphine and to assess vital
signs and assess post operative dressing Patient’s primary diagnosis, date of
admission, current orders for patient
ASSESSMENT
Lower left leg looks cyanotic, dressing seems really tight, prolonged
capillary refill in the toes on the left side, normal skin turgor, skin is
Current pertinent assessment data using head cool and she is very sweaty
to toe approach, pertinent diagnostics, vital
signs
RECOMMENDATION
Recommendations is to loosen dressing, assess pedal pulses, vital
signs q 15 mins, provide PRN medication for pain, assess pain,
circulation Any orders or recommendations you may have
for this patient
Clinical Worksheet
Date: 4/12/2020 Student Name: Karen Brito Assigned vSim: Marilyn Hughes
Initials:
MH
Age:
45
M/F:F
Code Status:Full
Diagnosis:
Compartment
Syndrome
Length of Stay:
1
dayAllergies:N
/A
HCP:N/A
Consults:N/A
Isolation:N/A
Fall Risk:
N/ATran
sfer:N/A
IV Type:
Location:
RUA
Fluid/Rate: IV of
Lactated Ringer’s
infusing at 75 mL/hour
Critical Labs:N/A Other Services:N/A
Consults Needed:N/A
Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: Patient is in hospital because she suffered a left mid-
shaft tibia-fibula fracture when she slipped on icy stairs this morning. She was taken to surgery for an open reduction with internal fixation (ORIF).
Health History/Comorbities (that relate to this hospitalization):
Shift Goals/ Patient Education Needs:
- Loosen Dressing
- Assess pedal pulses
- Assess vital signs q 15
- Assess for signs of bleeding of infection
Path to Discharge: Make sure that circulation returns to left lower extremity and pulses/color return to leg
Path to Death or Injury: No promotion to leg can lead to thrombus/clot
Reflection Questions
Paste your reflection questions in the box below
. How did the scenario make you feel?
I am comfortable with compartment syndrome, therefore I felt ok during this assignment.
- How would you recognize that Marilyn Hughes’ condition was deteriorating?
She would show signs of increased pain, such as increased blood pressure, heart rate, and respirations. She would also complain that medication isn’t reducing her pain.
Her feet and toes would also become pale and pulseless.
3. What interventions exist to alleviate compartment syndrome, and what assessments indicate improved perfusion to the extremity?
Lowering the leg to heart level which will increase circulation to the extremity, loosening the dressing so that it is not so tight, signs of improved perfusion
which includes return of color to the foot, and the return of pedal pulses.
- Why is it important to maintain the limb at heart level versus elevating it above heart level?
Having the limb at heart levels improves arterial perfusion and prevents further fluid accumulation.
- What could have happened in this scenario if Marilyn Hughes’ condition was not treated expediently?
If the patient’s circulation the limb is not restored, she could potentially lose her limb due to ischemia of the tissues.
- What key elements would you include in the handoff report for this patient? Consider the SBAR (situation, background, assessment, recommendation) format.
Marilyn Hughes is a 45-year-old female who suffered a left mid-shaft tibia-fibula fracture when she slipped on icy stairs this morning. She was taken to surgery for an open
reduction with internal fixation (ORIF). She returned from surgery at 1:45 p.m. with a below-the-knee ace/splint dressing. Vital signs have been stable, and
neurovascular checks have been within normal range. She has an IV of Lactated Ringer’s infusing at 75 mL/hour and is tolerating liquids well without nausea. Her diet
could probably be advanced to regular dinner this evening. A family member has been with her at the bedside throughout the day. She began complaining of pain
shortly after returning from surgery and was given morphine 6 mg IV at 2:15 p.m. She is now on every-30-minute postoperative vital signs. Last vital signs were BP:
130/82, HR: 88, RR: 16.
- What would you do differently if you were to repeat this scenario? How would your patient care change?
I would know the signs of compartment syndrome and how to assess it earlier on.
Clinical Judgement Components
Scoring:
Exemplary = 4 point Accomplished = 3 points Developing = 2 points
Beginning = 1 point
Noticing:
Focused Observation: E A D B
Recognizing Deviations from
Expected Patterns: E A D B
Information Seeking: E A D B
Total for category :
Score: vSim 1
Score: vSim 2
Score: vSim 2
Interpreting:
Prioritizing Data: E A D B
Making Sense of Data: E A D B
Total for category:
Responding:
Calm, Confident Manner: E A D B
Clear Communication: E A D B
Well-Planned Intervention/Flexibility:
E A D B
Being Skillful E A D B
Total for category :
Reflecting:
Evaluation/Self-Analysis: E A D B
Commitment to Improvement: E A D B
Total for category :
