*NURSING > PATIENT ASSESSMENTS > NURS 225 Marilyn Hughes Feedback Log & Score (All)

NURS 225 Marilyn Hughes Feedback Log & Score

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1:10 Patient status - ECG: Sinus tachycardia. Heart rate: 103. Pulse: Present. Blood pressure: 157/94 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 1:26 Yo... u identified the patient. To maintain patient safety, it is important that you quickly identify the patient. 1:33 You asked if the patient was allergic to anything. She replied: 'No, I am not allergic to anything.' 1:52 You attached the pulse oximeter. It is a good idea to monitor the saturation and pulse here. This will allow you to reassess the patient continuously. 2:10 Patient status - ECG: Sinus tachycardia. Heart rate: 104. Pulse: Present. Blood pressure: 156/94 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 2:15 You attached the automatic noninvasive blood pressure (NIBP) measurement cuff. This will allow you to reassess the patient continuously. 2:17 You looked for normal breathing. She is breathing at 21 breaths per minute. The chest is moving normally on both sides. 2:40 You checked the temperature at the mouth. The temperature was 99 F (37 C). 2:57 You checked the radial pulse. The pulse is strong, 105 per minute and regular. It is correct to assess the patient's vital signs. 3:10 Patient status - ECG: Sinus tachycardia. Heart rate: 105. Pulse: Present. Blood pressure: 157/94 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 3:13 You asked the patient if she had any pain. She replied: 'Yes! Ahh...' https://simserver.wkhpe.com/debriefing/debrief.aspx?dss=https%3A%2F%2Fsso.wkhpe.com%2FDebriefingLog%2FSingle%2F0e2e95e8-779d-4f3c-a159-297e23b1a… 1/4 3:19 You asked the patient if anything made the pain better. She replied: 'No. Please give me something for the pain!' 3:26 You asked the patient if anything made the pain worse. She replied: 'It gets worse when somebody touches my leg.' 3:45 You asked the patient if she could describe her pain. She replied: 'It feels like the bandage is too tight.' 3:51 You asked the patient where the pain was located. She replied: 'It's in my left leg.' 4:00 You asked the patient if the pain went anywhere. She replied: 'No, not really.' 4:05 You asked: How bad is the pain? She replied: 'It's really bad, about 8.' 4:10 Patient status - ECG: Sinus tachycardia. Heart rate: 106. Pulse: Present. Blood pressure: 153/92 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 4:15 You asked the patient how long she had pain for. She replied: 'Since I got back from surgery...' https://simserver.wkhpe.com/debriefing/debrief.aspx?dss=https%3A%2F%2Fsso.wkhpe.com%2FDebriefingLog%2FSingle%2F0e2e95e8-779d-4f3c-a159-297e23b1a… 2/4 4:35 You examined the patient's legs. The lower left leg looks cyanotic. The dressing seems really tight. There is prolonged capillary refill in the toes on the left side. There is normal skin turgor. Her skin is cool, and she is very sweaty. 4:35 You have performed a Glasgow Coma Scale (GCS) assessment by checking relevant responses. The GCS is 15. 5:06 You lowered the patient's leg. This is correct. It is recommended to lower the extremity to heart level since this may improve arterial perfusion. 5:10 Patient status - ECG: Sinus tachycardia. Heart rate: 106. Pulse: Present. Blood pressure: 157/94 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 5:18 You assessed the patient's dressing. This is correct. Assessing any dressings the patient has is always important. 5:40 You checked the pedal pulse. The pulse is strong, 105 per minute and regular. The pulse is absent on the left side, though. Correct. This is part of a neurovascular assessment when compartment syndrome is suspected. 6:10 Patient status - ECG: Sinus tachycardia. Heart rate: 107. Pulse: Present. Blood pressure: 157/94 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 6:20 You listened to the lungs of the patient. The breath sounds are normal. 6:39 You loosened the restrictive dressing. This is correct as it improves arterial perfusion. 6:53 You asked the patient how she felt. She replied: 'Not good; it's actually worse.' 7:10 Patient status - ECG: Sinus tachycardia. Heart rate: 106. Pulse: Present. Blood pressure: 155/92 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 7:26 You assessed the patient's IV. The site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact. This is correct. Assessing any IVs the patient has is always important. 7:48 You asked the patient if she could move her toes. She replied: 'No. I don't think so.' 7:57 You asked the patient if she could feel her toes. She replied: 'My left foot feels really numb.' 8:10 Patient status - ECG: Sinus tachycardia. Heart rate: 104. Pulse: Present. Blood pressure: 157/93 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 8:11 You examined the patient's legs. The lower left leg looks cyanotic. There is prolonged capillary refill in the toes on the left side. There is normal skin turgor. Her skin is cool, and she is very sweaty. 8:12 You have performed a Glasgow Coma Scale (GCS) assessment by checking relevant responses. The GCS is 15. https://simserver.wkhpe.com/debriefing/debrief.aspx?dss=https%3A%2F%2Fsso.wkhpe.com%2FDebriefingLog%2FSingle%2F0e2e95e8-779d-4f3c-a159-297e23b1a… 3/4 https://simserver.wkhpe.com/debriefing/debrief.aspx?dss=https%3A%2F%2 [Show More]

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