NF3 report
Vitals Assessment
Vital signs are collected as a preliminary assessment to identify key issues.
Notable vitals mentioned:
Temperature: 38.2°C
Heart Rate: 110 bpm (assumed from context)
Pain Level: 8/10
Other symptoms: Fatigue, nausea, poor appetite.
Patient Profile
Patient Name: Justin Lee
Age: 57 years old
Status: Post-operative day two
Surgery Type: Surgical debridement
Debridement Definition: Surgical removal of dead, damaged, or infected tissue to promote healing.
Symptoms and Observations
Current Condition:
Patient is awake and oriented to time, place, and person.
Appears fatigued.
Intermittent grimacing noted when his left foot is moved.
Described pain as throbbing and burning, relieved by elevation.
Pain worsens with movement.
Additional Symptoms:
Ongoing nausea.
Poor appetite, only taking small sips of fluids.
Declined breakfast, no vomiting reported.
Wound Observation:
Left foot wound is warm, red, and mildly swollen.
Functional Limitations
Justin requires assistance with transfer due to pain;
He is hesitant to mobilize,
Expresses exhaustion and pain exacerbation during attempts to move.
Psychosocial Factors
Patient displays signs of isolation; no family present at bedside.
Concerns: Expresses worry about worsening condition.
Problem Identification
Major issues identified from the assessment include:
Pain management
Infection risk due to post-operative state.
Mobility issues due to pain and fatigue.
Psychosocial dimension such as isolation and anxiety.
Nausea and poor appetite affecting recovery.
SBAR Communication Framework
Situation: Patient Justin Lee, 57 years old, post-op day two with significant pain and lack of mobility. Notable changes in condition suggesting potential complications.
Background: No known allergies (except shellfish). Previous health issues relevant to current status must be acknowledged.
Assessment (A):
Vitals:
Temperature: 38.2°C
Pain: 8/10 (throbbing, burning)
Heart rate recorded earlier.
Subjective data: Nausea, poor appetite, fatigue, grimacing when moving left foot.
Nursing Interventions to Address Issues
Pain Management
Conduct thorough pain assessment using PQRST framework:
P (Provocation): What causes the pain?
Q (Quality): Type of pain (throbbing, burning).
R (Region): Pain location (left foot).
S (Severity): 8 out of 10.
T (Timing): When does it occur?
Non-Pharmacological Interventions:
Continue to elevate the foot.
Implement relaxation techniques to reduce environmental stressors.
Pharmacological Options:
Administer Hydromorphone, Tylenol, monitoring for effectiveness and side effects (considering fever as well).
Infection Management
Frequent monitoring of vitals to assess for signs of infection.
Employ Rita TACO method:
TACO: Temperature, Appearance, Comments, Observe
Dressing changes to keep the wound clean, dry, and protected to prevent infection spread.
Report any signs of increased infection (redness, purulence).
Managing Nausea
Assess for further signs of obstruction if bowel sounds are absent.
Medications: Administer anti-nausea medications such as:
Diphenhydramine,
Ondansetron,
Non-Pharmacological Interventions:
Encourage small sips of non-sugar ginger ale.
Use of cold cloth to relieve nausea sensation.
Patient Education:
Advise on elevating the head while resting to prevent reflux and enhance comfort during recovery.
Team Collaboration and Presentation Preparation
Each nursing team member must prepare their assessments, interventions, and present findings in an organized manner, covering aspects of:
Pain assessment and interventions.
Infection management strategies.
Nausea assessment and supportive care explanations.
Documentation
Following the presentation, document findings on assessment sheets (DARK template).
Ensure all subjective and objective data, along with intervention outcomes, are accurately recorded for ongoing patient care.