Documentation Assignment
1. Document a comprehensive pain assessment for Marilyn Hughes.
2. Document Marilyn Hughes’ neurovascular assessment
Guided Reflection Questions
How did the scenario make you feel? How would you recognize that Marilyn Hughes’ condition was deteriorating?
1. Document a comprehensive pain assessment for Marilyn Hughes.
During the first assessment Marilyn graded her pain at an 8/10 saying the pain was in her
left leg, because the dressing was too tight. After completing the interventions, she
graded her pain a 4/10, still in her left leg, but also said that she felt much better now.
2. Document Marilyn Hughes’ neurovascular assessment.
She said her whole left leg felt numb and was not able to move or feel her toes on her left
side. There was no pulse present on the left foot.
3. Document the changes in Marilyn Hughes vital signs.
During my initial assessment, Marilyn’s vital signs included a pulse of 105, blood
pressure of 150/90, respirations of 21, SpO2 of 98% and temperature of 99F. After doing
my interventions her vital signs were heart rate 97, blood pressure 144/86, Respirations
19, SpO2 97%, and temperature 99F.
4. Identify and document key nursing diagnoses for Marilyn Hughes.
Acute pain related to left tibia-fibula fracture as evidenced by self-report of a pain
intensity of 8 using the numeric rating scale.
Ineffective tissue perfusion related to increased fascia pressure as evidenced by absent
pulse and altered sensation.
5. Referring to your feedback log, document the nursing care you provided and Marilyn
Hughes’ response to this care.
After pain assessment, I assessed the dressing on her left leg, it was too tight and was
causing pain to patient so then I loosen the dressing and placed patient`s leg at heart level
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