Assignment Task

You are still caring for your patient from Assessment 2. An acute event happens to your patient which requires your detection and action to resolve, using the Nursing Process. You will be required to document a transcript of the ISOBAR handover you would give when reporting the acute event to the medical team, as well as document the event using the Data/Action/Response (DAR) method into the patient’s integrated 

SCENARIO

Emily is on Day 2 post-op following an ORIF of her # R) femur. She has a Varivac drain in situ at the wound site, which was draining haemoserous fluid from the wound when you cared for Emily on your PM shift yesterday (canister half full). You are on an AM shift today. You complete Emily’s vital signs at 0800 which are WNL, but Emily reports that she has pain at her surgical site. You assess her upper right leg and it looks swollen. You check Emily’s Varivac drain and the vacuum indicator is in a U shape.

Questions

1. What are the assessment findings from this scenario which alert you to there being a problem?

2. What is Emily’s main problem outlined above that you need to address? What has caused this problem? Please explain the potential adverse outcomes that may occur if the problem is not resolved.

3. Outline your plan of care for Emily for the next 2 hours, to begin to resolve this problem. For every intervention in your care plan, please document a rationale for your action. Your rationale must be referenced. 

4. You call the medical team to handover Emily’s current situation and request for her to be medically reviewed. Please document your ISOBAR handover, SPECIFIC TO HER CURRENT PROBLEM ONLY.

5. You are required to document in the integrated notes. Please document your integrated notes of what has occurred for Emily specifically relating to this problem, using the DAR method. Please assume that you have implemented your initial strategies but are awaiting an outcome at time of report (ATOR).

6. What is your expected outcome for Emily, and how will you evaluate whether your care plan has been effective in achieving this outcome?

7. Three days later, the medical team has determined that Emily no longer requires the Varivac drain and has ordered it to be removed as she is going to be discharged home. Please provide a transcript of your education to Emily before undertaking this procedure.

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