Surgical Case 5: Lloyd Bennett
Documentation Assignments
1. Document your focused postoperative assessment for Lloyd Bennett.
Check for Hemorrhage and bleeding; assess for neurovascular compromise; prevent dislocation
of prosthesis; asses for deep vein thrombosis; monitor for infection related to surgery
2. Document Lloyd Bennett’s allergies in his chart.
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No known allergies
3. Document Lloyd Bennett’s vital signs during the transfusion reaction.
112/73- 97- 19- 94% Temp- 99.0 oral
4. Document the priority nursing actions completed during the transfusion reaction.
1. Stop transfusion immediately.
2. Replace tubing containing blood with new tubing primed with NS, DO NOT flush IV tubing
3. containing blood;
4. continue to maintain IV access.
5. Check Vital Signs.
6. Notify provider while staying with patient.
7. Verify the PT ID matches the blood label.
8. Treat symptoms.
9. Notify the blood lab as per hospital policy
5. Identify and document key nursing diagnoses for Lloyd Bennett.
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Acute pain r/t total hip replacement
Impaired physical mobility related to positioning, weight bearing, and activity restrictions after
total hip arthroplasty
Risk of falls r/t history of falls
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6. Referring to your feedback log, document the nursing care you provided.
1. hand washing
2. introduce self
3. Identify patient
4. Check for allergies
© Wolters Kluwer Health | Lippincott Williams & Wilkins
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5. Provide pt education.
6. Obtain informed consent
7. assess- lung sounds, and heart sounds
8. Take Vital Signs
9. Assess Pt surgical dressing
10. Assess IV site for s/s infection
11. Verify blood, patient ID and type and cross-match by two nurses
12. Flush IV with NS than Infuse the packed reb blood cells at 100 ml/hr
Patient states he is having back pain- PT has started to develop a transfusion reaction
13. Take Vital Signs
14. Call MD with SBAR info
15. Obtain new orders for N/S 100 ml/hr, U/A C&S and Venous blood sample
16. Contact blood bank
17. Start IV fluids NS 100 ml/hr
18. Obtain U/A and culture
19. Obtain venous blood sample
20. Ask patient if he’s having any pain, patient stated he was pain medication offered, Pt denied.
© Wolters Kluwer Health | Lippincott Williams & Wilkins
This study source was downloaded by 100000804137502 from CourseHero.com on 11-05-2021 07:37:27 GMT -05:00
https://www.coursehero.com/file/54624575/Lloyd-Bennett-documentation-assign-completeddocx/
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