Wound care DAR

[elena_2014]

Hello,

i just started the LVN program and have to come up with 2 focus statements, Data, response for this pt:Mr p. brain 56 y.o. Dx:left hip fx; S/P ORIF C/O surgical site pain. Wound care: cleanse left hip wound with NS, pat dry, apply DSD. Wound appearance _________________

complete 2 DARs for this patient. Not all of the assessment data has been provided. Please fill in the blanks as needed. You may also be creative and add additional data.

Please help to come up with two DARs!!! Many thanks!!

[TheCommuter, BSN, RN]

Please help to come up with two DARs!!! Many thanks!!

I'm sure your nursing program instructor wants you to formulate the DAR by yourself, without help from strangers on the world wide web. There's a purpose for this. It helps to develop your capabilities for critical thinking and seeing the big picture when providing nursing care for the patient.

I will formulate two DARs, but not for your aforementioned patient in the above-mentioned scenario. Instead, I'll create a scenario of my own and generate two DARs based off my imagination.

Ms. V is a 96 y.o. with a dx of left hip contusion S/P ground level fall at home; C/O dull pain to left hip with a numeric pain level rating of 4/10. Wound care: none (no open wound upon assessment). Assessment reveals a discolored area to the left hip that measures 5cm X 5.5cm.

1. D = At 1:00pm patient Ms. V states, "My left hip hurts!" Reports a numeric pain level of 4/10; states the pain is dull and achy. Assessment reveals a discolored area to the left hip measuring 5cm X 5.5cm; Vital signs 97.1, 88, 19, 126/82.

2. A = This writer administered acetaminophen 500mg orally per physician order. Patient Ms. V repositioned and placed in semi- Fowlers with head of bed elevated 60 degrees. Ice applied to left hip per physician's order for 20 minutes.

3. R = At 1:45pm patient Ms. V states, "The pain went away!" Pain level of 0/10 reported. Vital signs 96.9, 80, 17, 118/78.

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1. D = At 3:00pm patient Ms. V states, "My left hip feels swollen!" Reports a numeric pain level of 1/10; states the area feels warmer than usual. Assessment reveals a discolored, swollen area to the left hip measuring 5cm X 5.5cm; 2+ edema noted. Vital signs 96.9, 79, 16, 118/76.

2. A = This writer placed patient in a side-lying position on the right side. Applied ice to the left hip for 20 minutes per physician order. Administered 20mg of furosemide (Lasix) per physician order.

3. R = At 4:30pm Patient Ms. V states, "I feel less swollen!" Patient urinated 500cc of clear straw colored urine. Left hip area is no longer edematous. Vital signs 96.8, 78, 16, 116/76. Pain level of 0/10 reported.

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I used my imagination to create these DARs, and your instructor is allowing you to use your imagination to create your DARs. Now get to work. :)

[elena_2014]

Thank you!! I have to describe the wound and have no clue if this wound will have width since it's post surgery. I will describe the sutures being intact. Will this wound have a width or just the length?

[TheCommuter, BSN, RN]

Thank you!! I have to describe the wound and have no clue if this wound will have width since it's post surgery. I will describe the sutures being intact. Will this wound have a width or just the length?

All wounds, even surgical incisions, have a width and a length. Of course, most incisions aren't terribly wide, so keep that in mind when you create a width.

[elena_2014]

Thank you!!

[Natasha A., CNA, LVN]

How is the lvn program going so far?