Exam (elaborations) NURS 267 Med-Surg Josephine Morrow Feedback Log &

Exam (elaborations) NURS 267 Med-Surg Josephine Morrow Feedback Log & You arrived at the patient's side. 0:00 You reviewed the patient information. 0:00 You reviewed the diagnostics. 0:00 You reviewed the MAR. 0:00 You reviewed the orders. This study source was downloaded by from CourseH on :17:26 GMT -05:00 This study resource was shared via CourseH 1/19/2020 Feedback Log & Score — Josephine Morrow Jan 19, 2020 11:57 AM 0:00 You reviewed the intake and output. 0:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 123/81 mm Hg. Respiration: 20. Conscious state: Appropriate. SpO2: 94%. Temp: 98 F (36.6 C) 0:12 You introduced yourself. This was reasonable. 0:18 You washed your hands. To maintain patient safety, it is important to wash your hands as soon as you enter the room. 1:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 121/80 mm Hg. Respiration: 20. Conscious state: Appropriate. SpO2: 94%. Temp: 98 F (36.5 C) 1:31 You identified the patient. To maintain patient safety, it is important that you quickly identify the patient. 1:40 You asked if the patient was Allergyallergic to anything. She replied: 'Yes, I am allergic to penicillin.' 1:58 You attached the Pulseoximeterpulse oximeter. It is a good idea to monitor the saturation and pulse here. This will allow you to reassess the patient continuously. 2:01 You looked for normal breathing. She is breathing at 20 breaths per minute. The chest is moving equally. 2:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 121/81 mm Hg. Respiration: 20. Conscious state: Appropriate. SpO2: 94%. Temp: 98 F (36.4 C) 2:23 You checked the radial pulse. The pulse is strong, 95 per minute, and regular. It is correct to assess the patient's vital signs. 2:45 You checked the Temperaturetemperature at the ear. The temperature was 97 F (36.3 C). 3:06 You measured the Bloodpressureblood pressure at 122/80 mm Hg. It is appropriate to monitor the patient by measuring the blood pressure. 3:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 122/81 mm Hg. Respiration: 20. Conscious state: Appropriate. SpO2: 94%. Temp: 97 F (36.3 C) 3:24 You put on gloves. 3:36 You assessed the patient's dressing. This is correct. Assessing any dressings the patient has is always important. 3:46 You asked the patient if she had any pain. She replied: 'No, I don't have any pain.' 3:58 You examined the patient's legs. There is moderate edema and hyperpigmentation of the skin from the knees and down on both sides. There is a dressing covering the skin lesion on the lower leg. There is normal elasticity of the skin. Her color is normal, and she is not sweating. 4:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 124/81 mm Hg. Respiration: 20. Conscious state: Appropriate. SpO2: 94%. Temp: 97 F (36.3 C)           This study source was downloaded by from CourseH on :17:26 GMT -05:00 This study resource was shared via CourseH 1/19/2020 Feedback Log & Score — Josephine Morrow Jan 19, 2020 11:57 AM 4:32 You educated the patient about wound care. This was reasonable. 5:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 121/80 mm Hg. Respiration: 20. Conscious state: Appropriate. SpO2: 94%. Temp: 97 F (36.2 C) 5:46 You removed the dressing. This was reasonable. However, make sure to dress the area appropriately again when possible. 6:01 You irrigated the wound with saline. This was reasonable. 6:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 121/80 mm Hg. Respiration: 20. Conscious state: Appropriate. SpO2: 94%. Temp: 97 F (36.2 C) 6:10 You assessed the patient's ulcer. This was reasonable. The ulcer is shallow, 1 inch in width, and looks mostly pink to red, with no signs of necrosis or infection. 6:30 You applied a dressing. This was reasonable. 6:49 You applied compression stockings. 7:02 You elevated the patient's legs. This was indicated by order. You should have educated the patient about improving venous return here. 7:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 122/81 mm Hg. Respiration: 19. Conscious state: Appropriate. SpO2: 94%. Temp: 97 F (36.1 C) 7:20 You educated the patient about positioning. 7:35 You educated the patient about diet. This was reasonable. 8:09 You educated the patient about activities, safety, and fall risk. 8:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 124/81 mm Hg. Respiration: 19. Conscious state: Appropriate. SpO2: 94%. Temp: 97 F (36.1 C) 8:31 You phoned the provider in order to discuss the patient. 9:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 123/81 mm Hg. Respiration: 19. Conscious state: Appropriate. SpO2: 94%. Temp: 97 F (36.1 C) 9:47 You removed the gloves. 9:53 A patient handoff was performed. This patient is an obese, 80-year old female in a skilled nursing home care facility with a venous stasis ulcer. The students are expected to assess the leg wound, assess the patient's pain, and perform a dressing change. The students are also expected to assess lab values, and provide patient education on interventions to promote venous return. Venous stasis ulcers occur in the lower extremities from impaired venous circulation and are usually shallow with an irregular shape over bony prominences, particularly the medial malleolus. Hypertension in the venous system of the legs can lead to pain, edema, varicose veins, skin changes,              This study source was downloaded by from CourseH on :17:26 GMT -05:00 This study resource was shared via CourseH 1/19/2020 Feedback Log & Score — Josephine Morrow Jan 19, 2020 11:57 AM dermatitis, hyperpigmentation, and venous stasis ulcer formation. The most important aspect of venous ulcer treatment is prevention with adequate compression therapy, using an elastic bandage and antiembolism stocking, and optimizing venous return. The surrounding skin should be inspected daily, keeping it clean and well-lubricated. Le