Disease:  Body System / Pathophysiology: Assessment Findings- (What should I see?  Objective vs. Sub

Disease:  Body System / Pathophysiology: Assessment Findings- (What should I see?  Objective vs. Subjective findings) Signs & Symptoms Diagnostic Procedures / Labs- (Why was it done?   What are the results?  Normal vs. Abnormal?)          Treatment / Meds. Reason for Treatment / Meds-(Why is this patient taking this med?  Why was this med added to the treatment plan?) Nursing Considerations Nursing Diagnosis(es) Patient Education / Dietary Considerations / Follow-up       Go to EHR Tutor and select William Harmon.  Review the EHR of Mr. Harmon. William Harmon is a 78 y/o post op Left hip fracture with ORIF.  Post-surgery, he’s developed two additional wounds.  Describe what needs to be included in the assessment of each of these wounds: Bruise on left hip from initial fallSurgical site for ORIFHeel bruiseReddened coccyx After reviewing all the records, complete the following activities:   Assess and document all the wounds this patient has.  Chart in the flowsheet – under “wounds, incisions, and drains” for each wound.  Make sure you differentiate the wounds in your charting so other practitioners understand which wound is which.Upon assessment of the coccyx wound, you have determined that the wound has progressed from a Stage 1 to a Stage 4 pressure ulcer.  Search the internet or your personal resources for a photo or image of a stage four pressure ulcer.  After that, you need to contact the physician about updating the wound treatment plan.  Determine what the best treatment would be and fill out an SBAR form and write a note documenting your call .Enter the new orders. You also need to teach your patient and/or family. Document patient teaching under the patient education tab in the EHR.Create a concept map and individualize it to this patient.  Wound Summary: William Harmon is a 78 y/o post op Left hip fracture with ORIF.  Post-surgery, he’s developed two additional wounds. Bruise on left hip from initial fallSurgical site for ORIFHeel bruiseReddened coccyx (progressed from stage 1 to stage 4)          Health Science Science Nursing NUR 211 Share QuestionEmailCopy link Comments (0)

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