Lab 3
Kelly Francis
Kelly Francis is a 58 year old female who had a complete mastectomy of her R breast after a diagnosis of stage 4 carcinoma. Her surgery was yesterday and you have been told she had a restful night with sedation. Her nursing assessment shows a history of high cholesterol and hypertension both managed by medications. She is supported by her husband of 35 years and her 2 grown children.
Post-operatively she has a Jackson Pratt drain in place and an occlusive dressing on her R side where the breast was removed. She has an IV infusing. She has not been up to ambulate post operatively and her care plan shows that she is to attempt ambulation today.
After reviewing the chart you come in to assess Kelly Francis she is in semi-fowler’s position and her eyes are closed. She appears to be resting quietly.
What are your first steps when meeting Kelly Francis?
Once you are able to speak with Kelly Francis you find her to be very soft spoken and tearful. What types of communication techniques would you use/what would you say to Kelly Francis?
What are some of issues you feel could be causing Kelly Francis to be tearful and upset?
Upon physical examination of Kelly Francis you assess her vital signs to be BP 128/82 P-100, R- 19, T- 37.9 °C . What is your assessment of these vital signs?
What other physical observations would you make? Assess Kelly Francis.
Note any unusual findings from assessing Kelly Francis, what would be your response to each of the findings.
2 hours into your shift you go in to check on Kelly Francis and to get her up into a chair. You find her complaining of a headache and pain from her surgical site. She also states that she is having difficulty focusing with her eyes.
What are your first steps to getting Kelly Francis up and into a chair?
What are some reasons Kelly Francis could be complaining of a headache and difficulty focusing?
What are your assessments and nursing interventions for Kelly Francis at this time?
Additional Questions
Your patient is wearing TED stockings, what are the indications for wearing TED stockings?
Your orders have a choice of IV or IM….what are the indications and benefits for one method over another?
Instructions for Lab Techs – Scenario #2
Kelly Francis Mannequin – 58 years old
Radical mastectomy R breast
Jackson Pratt drain – torn out of site (but hidden under covers)
If possible serous drainage in the bulb of the JP drain – approx 45 cc
Occlusive dressing on R breast site – some serous drainage
TED stockings on mannequin, all rolled up and wrinkled
IV infusing N/S – show less in bag that should be based on I+O flowsheet in chart
Have pain meds in minibag from 2 hours prior
Put a urinary catheter in patient
No name band on patient
Allergic to morphine & eggs
Chart
Note JP Drainage to be around 30 cc per 8 hour shift
Physician’s orders
IV N/S at 125 ml/hour
Orders for post op pain relief – Demerol 75 mg q4h prn and Gravol 50 mg q4h prn IV or IM
Hypertension meds – Adalat XL 60 mg po OD
High cholesterol meds – Lipitor 10 mg qhs
I&O
Dressing change OD
Show a med error on MAR – ie. Cholesterol Medication given BID and ordered OD
Orders to D/C catheter at 8 hours post-operatively
Vital signs flowsheet – show trend of stable BP and pulse – slightly elevated (around 130/85)
