vSim Health Assessment Case 3: Sara Lin Documentation Assignments. Questions & Answers.

Health Assessment Case 3: Sara Lin Documentation Assignments 1. Document your findings and Ms. Lin's reactions related to the focused assessment of her current pain status. Patient reported of having sharp stabbing pain right lower quadrand and stomach. Patient reported pain was “Not to bad; it’s about a 3.” Patient reports pain is worse when she moves around, and gets better when she is still. 2. Document your findings and Ms. Lin's reactions related to the abdominal assessment performed. Bowel sounds present in all 4 quadrants, the abdominal countour is slightly distended, abdomen does not buldge when patient raises, tento to light palpation with rebound tenderness present, pain reaction when palpating the lower right quadrant. 3. Referring to your feedback log, document all nursing care provided and Ms. Lin's response to this care. Patient alert and oriented x2 (place and time), able to follow simple commands, speech clear and understandable, no tremors; reports pain of “3” on a scale from1/10, states pain medication helps, but better if still, denied any mediation for pain; last meal was “around 2 this morning;” lmp 2 weeks ago; last bowel movement was yesterday, patient reported two bowel movement a day with normal consistency; last voided in the emergency room; denies any medical problems; no vein distension or visinle pulsations, in the thorax, back, no lesions, scarring, vein distention or visible pulsations; skin color normal color, odor, and skin integrity; radial and pedal pulses strength +2 bilaterally, capilarry refill 2 seconds; IV side had no redness, swelling infiltration, bleeding, or drainage, dressing was dry and intact; abdoinal countour slightly distended. 4. Document all patient teaching regarding assessments, care, medications, and safety issues provided to Ms. Lin, and her response to the teaching.