Jared Griffin
Documentation Assignments
1. Document your finding related to Mr. Griffin's preoperative and postoperative
assessment findings regarding the presence of an infection.
a. Mr.Griffin’s peroperative assessment demonstrates signs & symptoms of an
infection. After a nasal swab, Mr. Griffin tested positive for MRSA. Mr. Griffin’s
postoperative assessment shows no signs & symptoms of an infection based on
the stable vital signs, as no abnommal values were indicated.
2. Identify and document key nursing diagnoses for Mr. Griffin regarding current
condition.
a. Delayed surgery for Mr. Griffin due to MRSA was a key nursing diagnosis.
Additional nursing diagnoses include activity intolerance during postoperative
care after his TKA surgery, decreased ROM due to his old age undergoing
surgery, & increased anxiety due to Mr. Griffin’s tenure at the hospital after his
surgery.
3. Referring to your feedback log, document all nursing care provided as well as Mr.
Griffin's response to this care, including responses related to infection control and
the use of personal protective equipment (PPE).
Mr. G, is a 63 year old male. I washed my hands, donned gloves & gown,
introduced myself, verified his name & DOB, & asked about any allergies. Mr. G
responded appropriately to all the questions. For further confirmation, he is
allergic to codeine.
His vital signs: blood pressure of 136/80, pulse of 80 beats per minute,
respirations of 15 breaths per minute, body temperature (ear) of 98 ° F (36.9 °
Celsius), & SpO2 of 97%. Skin his dry, w/ normal color & elasticity, & leg
dressing on the skin lesion of his leg. Capillary refill time of less than 2 seconds.
Mr. Griffin was compliant with the vital sign assessment.
Pain: 2/10. Assessment of the IV on his right side indicated no signs of drainage,
swelling, redness, bleeding, or infiltration. After assessing the dressing on his leg,
Mr. Griffin’s dressing remains dry & intact.
I educated Mr. Griffin on the importance of wound care, which he initially did not
know, person protective equipment, activities, safety, & fall risk, the use of the
incentive spirometer. Afterwards, I had Mr. Griffin use the incentive spirometer
as he was instructed. He was compliant to all of the interventions.
vSim for Nursing | Fundamentals. © Wolters Kluwer
4. Document your handoff report in the SBAR format to communicate Mr. Griffin's
future needs.
Situation: 65 year old African American male Jared Griffin under went a right
total knee arthroplasty (TKA) yesterday morning.
Background: Mr. Griffin has a history of MRSA, which was diagnosed 3 years
ago when he had surgery for hammertoe. A nasal swab was conducted during
preoperative check & results returned positive. Patient is under precaution
isolation as a result of hospital policy. In addition, Mr. Griffin has a history of
osteoarthritis & mild hypertension.
Assessment: Mr. Griffin’s vitals were stable, pain level 2, & no sign of infection
after checking the dressing. Mr. Griffin has an IV & a dressing on his right lower
leg, the site of his surgery. He was able to use the incentive spirometer
appropriately.
Recommendation: Staying alert of his vital signs, pain levels, checking on his
dressings for signs of infection, & continuing with precaution isolation measures
w/ his MRSA
vSim for Nursing | Fundamentals. © Wolters Kluwer