Question

TEMPLATE FOR POST-CONFERENCE PRESENTATIONS ON ASSIGNED JARED GRIFFIN

Clinical Post Conference Worksheet

I. SBAR-Report

II. Nursing process

Nursing Diagnosis that may apply to your patient’s situation (must be NANDA diagnoses and include all parts and must list at least 3 diagnoses; 2 actual and 1 risk for)

1. ________________________________________________________________________________________________________________________________________________
2. ________________________________________________________________________________________________________________________________________________
3. ________________________________________________________________________________________________________________________________________________

What is the priority diagnosis for this patient and why? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What is your short-term goal for this patient? (List at least one time referenced, pt oriented goal (outcome) that is measureable).

List at least two (2) nursing interventions for each NANDA that you will/have complete/d during your clinical hours:

List any upcoming labs, diagnostics and procedures

What is the plan for discharge?

Any additional consultations or resources needed to optimize pt’s care?

Did you delegate tasks related to patient care to another member of the health care team? What and to whom?

III. Patient teaching:

Learning need	Teaching done	Patient response	Re-evaluation

IV. Reflections

In addition to reporting on your patients, please consider these questions each week at the end of your clinical day and be ready to discuss in post conference with your group.

1.         What went well for you today?

2.         What can I improve?

3.         Describe the most important new learning that you experienced today.

4.         If you were caring for this patient tomorrow, what additions or changes would you make to your plan of care?

5.         Identify one area for further learning related to this patient assignment.

6.         Identify any questions concerning the rational for the delivery of this patient’s multidisciplinary plan of care.

PATIENT'S DATA

Location: Orthopedic unit 0800

SBAR report from a night nurse:

Situation: Jared Griffin is a 63-year-old African American male who had 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 a hammertoe. A nasal swab was done in the office during his recent preoperative check that came back positive for MRSA. Decolonization protocol was initiated prior to the admission for the total knee procedure and he is currently under contact precautions per hospital policy. He has a history of osteoarthritis and mild hypertension.

Assessment: Mr. Griffin is afebrile with a temp of 37.2 °C (99.8 °F), and vital signs have been stable during the night. Pain level has been at a 2–3. He has dangled his feet off the side of the bed and will have physical therapy in his room at 1000. He has been able to bend his knee to a 75-degree angle and the goal is 90 degrees. The surgeon changed Mr. Griffin’s dressing, and discontinued the drain and IV fluids, at 0700 on his morning round. His labs just came up, but I haven't had a chance to look at them yet.

Recommendation: You'll need to go in and do your morning assessment. Continue with contact precautions, and observe for signs and symptoms of infection. (Vsim online)

Answer 1

Nursing diagnosis are,

• Acute pain related to the surical wound
• Altered mobility related to the surgical procedure and dressing
• Altered comfort related to Total knee replacement surgery and AEB grimacing
• Risk for the infectiion related to the surgical wound and procedure

The prioritise diagnosis are,

• Acute pain related to surgical wound
• Risk for inferction related to the surgical wound

The short term goals are,

• Manage pain
• Prevent infection
• Maintain nutrition
• Give psychological support

Nursing interventions are,

• Administer analgesics for manage pain
• give elevated position for prevent edema
• give physiotherapy for the mobiliity and prevent edema
• give traction if required
• provide foot support and exercise for the prevention of foot drop
• Administer antibiotics for prevention of infection as prescribed by the doctor
• provide nutritional assistanse that give adequate amount of calcium and vit D
• give psychological support to cop up with the situation

The diagnostic evaluations are,

• Complete blood count for identify any blood loss and infection
• X-ray for assessing the success of the surgery

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