can someone tell me if this looks good? (Pathopysiology and assessment)

  1. Is there anything that sounds horrible that I should fix?
    Core Pathophysiology
    Surgery on her leg caused a large wound to develop. Deep somatic pain can develop from this. Deep somatic pain originates in deep body structures, such as the periosteum, muscles, tendons, joints and blood vessels.

    Nocireceptors, or pain receptors, are sensory receptors that are activated by noxious insults to peripheral tissues. Structurally, the receptive endings of the peripheral pain fibers are free nerve endings. These receptive endings are widely distributed in skin, dental pulp, periosteum, meninges, and some internal organs.

    Porth, C.M. (2005). Pathophysiology: Concepts of altered health states. (7th ed). Philadelphia: J.B. Lippincott. Pp. 1169, 1172

    Client Assessment
    M.B. is a 79 y/o woman admitted to Heartland on 9/26/05 with Malignant Neoplasm of mandible, extending to the floor of the mouth. M.B. underwent surgery to reconstruct her jaw after removing the cancer. They reconstructed the jaw with part of her bone in her right leg and skin from right thigh. The patient was being discharged on the day of my care. She was walking via walker and still in pain.

    0830- Elderly woman sitting up in bed with eyes open. HOB elevated.

    VS- Temp: 97.9F Pulse: 73 Resp: 20 B/P: 121/54

    Neuro: A&Ox3. PERRLA

    CV: Apical Irregular= 73. Peripheral pulses present in all extremities. Pulse in Right foot weaker than Left. Extremities warm. Edema Right knee to foot. +1 nonpitting. Cap refill < 3 seconds.

    Resp: Lung sounds clear posterior and anteriorly. Rate 20. Cough moist. Sputum a 'cream' color. Nail beds soft and pink. Mucous membranes pink with white patches and moist.

    GI: BSx4 quadrants, abdomen soft and nondistended. No BM on my shift. Pt. c/o constipation after a few days of no BM.

    GU: Able to ambulate to bathroom. Urine yellow, no sediment present.

    Intg: Skin warm, moist, smooth and soft. Wound on right lower leg. Black on posterior edges, pink with white patches. Skin graph on Right thigh, OTA no S&S of infection. Wound left side of face, extending from left ear to clavicle. OTA no S&S of infection. Trachestomy site closed, no drainage.

    MS: hand grasps equal and strong bilaterally. Passive & active ROM exercises possible. Feet push/pull exercises done, Right weaker than Left.

    Pain: c/o pain with dressing change. Pt. started to cry. Pain medication, oxycodon, was given. Checked on pt 30 min later. Pain reduced to a "3" on a 1-10 scale. Pt smiled when asked about pain.

    Psy/Soc: Very pleasant. Doesn't socialize very often but very receptive to my care. Waiting for husband to come pick her up. She dressed and showered independently. Smiles during conversation with me.
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  2. 10 Comments

  3. by   Kelly_the_Great
    Quote from lccougar02
    Intg: Skin warm, moist, smooth and soft. Wound on right lower leg. Black on posterior edges, pink with white patches. Skin graph on Right thigh, OTA no S&S of infection. Wound left side of face, extending from left ear to clavicle. OTA no S&S of infection. Trachestomy site closed, no drainage.
    lccougar02,

    Do you remember the measurements (width, length, depth) of the wounds?
  4. by   Daytonite
    Is this something you have written? Needs proofreading and correction of grammer. Some of it is very disconnected. The first thing that caught my attention was there is no mention of the specific kind of surgery on the patient's leg. I had to put two and two together after reading the entire thing. I would want to know up front the patient's disease and then the complete name of the surgery done including the bone grafting. The information you give in the pathophysiology is very nonspecific and does not make a clear connection to what is going on with this particular patient. Your client assessment sounds like a discharge summary a doctor would write, but included elements of a daily assessment making it kind of jumbled. Is this supposed to be a nursing assessment?

    I've sent you a PM.
  5. by   lccougar02
    Quote from Kelly_the_Great
    lccougar02,

    Do you remember the measurements (width, length, depth) of the wounds?
    No, we had our first day on the floor the other day and she never showed us the ruler to measure the wound, so she said dont worry about that part.
  6. by   lccougar02
    haha wow im glad i posted on here...i suck ha
  7. by   Kelly_the_Great
    Quote from lccougar02
    haha wow im glad i posted on here...i suck ha
    Hey Lccougar02,

    Nah, you don't suck. No nurse was born writing good assmts. initially, okay? It's like everything else, takes practice.

    I've seen a couple of other postings you've made regarding doing this project. The fact that you care about doing a good job says a lot about you.

    Hang in there!
    Last edit by Kelly_the_Great on Oct 9, '05
  8. by   JentheRN05
    --
    Last edit by JentheRN05 on Oct 9, '05 : Reason: Changing my format
  9. by   JentheRN05
    SENT PM
    Last edit by JentheRN05 on Oct 9, '05
  10. by   lccougar02
    Kelly,
    Thanks for the encouragment, I need it haha. This paper is only worth 7 points but its not so much the points i am worried about. I really want to understand my faults and what I can do to improve. I would rather have people here help me then have my teacher criticise me haha.
    ~Jackie
  11. by   Kelly_the_Great
    Jackie,

    Did the teacher provide you with an outline of how she wanted this assignment completed? If so maybe you could attach that here and that could help us guide you.
  12. by   Daytonite
    Quote from lccougar02
    No, we had our first day on the floor the other day and she never showed us the ruler to measure the wound, so she said dont worry about that part.
    Note to self: carry some kind of little ruler with you in your pocket. You will need it again and again during your career.

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