Class notes
Lloyd Bennett VSIM
- Course
- PNUR205
This document provides post scenario documentation and guided reflection of Lloyd Bennett's case in VSIM Nursing.
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Surgical Case 5: Lloyd Bennett - Documentation Assignments1. Document your focused postoperative assessment for Lloyd Bennett.
● Initial post-op assessments
Orthopedic Floor, Room 123B
5/11/21 at 1030
The patient has NKA. oriented x3. Pt states no pain. IV site has no S&S of infection, hematoma, and
infiltration. Left leg was dry and intact. the patient states “i feel tired”. lungs and heart sounds are
normal. VS: spo2 94% ;P: 95, finger; temp: 37*C, bp: 103/87 left, lying; RR 17 bpm, chest moving normal
bilateral. The legs’ skin turgor is normal, but appears to be a bit pale. Labs: HCT & HgB noted to be low.
Patient cross-matches with the recipient's blood confirmed by 2 nurses.
2. Document Lloyd Bennett’s allergies in his chart.
Orthopedic Floor, Room 123B
5/11/21 at 1040h
Patient was given 100 mL/hour of packed RBC as per Doctor's order. patient c/o of back pain level 2/10 as
stated by “my back hurts''. Mr. Bennett displays anxiety as stated by consequently asking “What
happened to me?... my back hurt after you started the blood… What's going on? “. Blood transfusion was
D/C. Vital signs, IV site and denies difficulty breathing & nauseous but c /o chest tightness. Health care
provider and blood bank were notified.
3. Document Lloyd Bennett’s vital signs during the transfusion reaction.
● During the transfusion reaction, the patient c/ o back pain level of 2/10 and displays apparent anxiety.
The key changes that occurred with the patient’s vital sign include increased HR, increased BP, presence
of pain, increased RR, chest tightness.
KEY CHANGES VS initial after blood transfusion
pain none 2/10, back, provoked after blood transfusion
rr: 17 bpm 20 bpm
bp 103/87 119/76
pulse 95 98
4. Document the priority nursing actions completed during the transfusion reaction.
● Discontinuing the blood transfusion immediately
● Checking vital signs timely (q.5min, 15min, 30 minutes)
● Notifying the provider
● Verifying once again if the patient’s blood matches by 2 nurses
● Notify the blood bank
● observing clients closely with adverse reactions of the blood transfusion (chills, fever, low back pain, N&/V
pain at the iv site;itching, skin rash or hypotension) . Acute Hemolytic reaction: (listed above + chest
tightness, dyspnea, & anxiety)
● (“) and alleviating symptoms
● Monitor labs: Hg Hct
5. Identify and document key nursing diagnoses for Lloyd Bennett.’
, Surgical Case 5: Lloyd Bennett - Documentation Assignments
potential Dx:
● Ineffective breathing pattern, Impaired Gas Exchange
● Decreased Cardiac Output
● Fluid Volume Deficit/excess
● Impaired Skin Integrity
● Altered Tissue Perfusion
● Hyper/hyperthermia
● Risk for Infection, Injury
● High Risk for Injury
● Pain
6. Referring to your feedback log, document the nursing care you provided.
Orthopedic Floor, Room 123B
5/11/21 at 1030h
● Patient was found in supine position
● introduce self, performed hand hygiene, check two identifiers, check allergy and obtain consent prior to
care, cross-matched position patient to semi fowlers
● assessed how the patient is feeling
● VS and assessed IV access ,dressing and lower extremity (attached automatic NIBP, Pulse ox), checked
orientation x3
● auscultated heart and lungs
● At 10:40, obtained consent, flushed IV, given packed RBC via infusion pump 100 mL/hr as per Doctor's
order., flushed IV. Following, patient c/ o back pain level of 2/10 and expressess uneasiness. patient
verifies no nausea or difficulty breathing but c/ o chest tightness.
● D/C blood transfusion
● Reassessed VS signs, orientation, IV site
● Notified provider, new orders were performed: contacted blood bank, started IV N/S at 100mL/hr,
obtained urine sample & venous blood sample.
● Verified the patient blood: by two nurses, patient blood, id and type and if the cross match check out
● At 10:50h, infused IV right arm 100 mL/hr NS was infused and performed dr’s new order.
● The patient was educated about the situation that had occurred, informing and relieving the patient that
he’s going to be continually monitored until stable, notifying to let me know when S&S of reaction occurs
and if the patient has any questions. patient left in semi fowler’s position, call bell within reach.
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