NURS 267 Med-Surg Sara Lin Feedback Log & Score Appendectomy7/22/2020
Feedback Log & Score — Sara Lin Jun 20, 2020 07:43 AM
Date of Completion
Jun
... [Show More] 20, 2020 07:43 AM
Sara Lin
Age:
18 years
Diagnosis: Appendectomy
Score
0
0
0
100%
Feedback Log
0:00 You arrived at the patient's side.
0:00 You reviewed the patient information.
0:00 You reviewed the patient log.
0:00 You reviewed the diagnostics.
0:00 You reviewed the clinical observations.
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Feedback Log & Score — Sara Lin Jun 20, 2020 07:43 AM
0:00 You reviewed the MAR.
0:00 You reviewed the orders.
0:00 You reviewed the intake and output.
0:10 Patient status - ECG: Sinus rhythm. Heart rate: 99. Pulse: Present. Blood pressure: 136/81
mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 97%. Temp: 99 F (37.2 C)
0:12 You introduced yourself. This was reasonable.
0:22 You washed your hands. To maintain patient safety, it is important to wash your
hands as soon as you enter the room.
1:10 Patient status - ECG: Sinus rhythm. Heart rate: 99. Pulse: Present. Blood pressure: 136/81
mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37.1 C)
1:42 You identified the patient. To maintain patient safety, it is important that you
quickly identify the patient.
1:51 You asked the patient how she felt. (In pain) She replied: 'I just want to go
home. The pain makes it hard to do deep breathing and cough, though.'
2:10 Patient status - ECG: Sinus rhythm. Heart rate: 99. Pulse: Present. Blood pressure: 135/81
mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37.1 C)
2:11 You asked the patient: Where does it hurt? (In pain) She replied: 'Just my
belly, nowhere else really.'
2:19 You asked the patient if she could describe her pain. (In pain) She replied:
'I feel a sharp pain on the side, and my belly hurts and kind of
throbs.'
2:29 You asked: How would you rate your pain? (In pain) She replied: 'It's
pretty bad; I'd give it a 6. '
2:40 You asked if the patient was <Allergy>allergic<> to anything. (In pain)
She replied: 'No, I am not allergic to anything.'
2:48 You asked the patient if she had taken her medication, if any. (In pain) She
replied: 'No, I don't take any medication.'
3:10 Patient status - ECG: Sinus rhythm. Heart rate: 99. Pulse: Present. Blood pressure: 138/83
mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C)
3:33 You compared the medication label with MAR. This was reasonable.
3:46
A 5-mg dose of oxycodone was given orally. It is important to use the basic rights
of medication administration to ensure proper drug therapy. This was indicated by
order.
4:00 You gave the patient a sip of water.
4:10 Patient status - ECG: Sinus rhythm. Heart rate: 99. Pulse: Present. Blood pressure: 138/82
mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C)
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4:16 You compared the medication label with MAR. This was reasonable.
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4:28 A 500-mg dose of levofloxacin was given orally. This was indicated by order.
4:50 You compared the medication label with MAR. This was reasonable. 4:59
A 325-mg dose of acetaminophen was given orally. This was reasonable.
5:10 Patient status - ECG: Sinus rhythm. Heart rate: 99. Pulse: Present. Blood pressure: 136/81 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C)
5:12 You gave the patient a sip of water.
5:46 You examined the patient's abdomen and pelvis. There is a dressing covering the skin lesion on the abdomen. There is normal elasticity of the skin. Her skin is cool, and she is very sweaty. There is nothing else to find on examination of the abdomen and pelvis.
6:10 Patient status - ECG: Sinus rhythm. Heart rate: 99. Pulse: Present. Blood pressure: 137/82 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C)
6:28 You listened to the abdomen of the patient. Normal bowel sounds were heard.
6:46 You attached the <Pulseoximeter>pulse oximeter.<> It is a good idea to monitor the saturation and pulse here. This will allow you to reassess the patient continuously.
6:56 You checked the [Show Less]