NRSG240

CONTEXTS OF NURSING 4
WEEK 6 LAB

Ms Ruby Cheng

DAY 4

NURSING HANDOVER

Ruby had an uneventful night, sleeping for long periods. Ruby

continues to use the PCA when she gets pain. Ruby’s pain score is 2/10
when laying in bed still but when she has to go to the toilet or move
around the pain in the knee is 6-7/10. The wound drain was removed
yesterday. Dr. Alverez (surgeon) has come to review Ruby’s wound
and has noted in the progress notes that the wound is slightly sloughy
requiring a daily irrigation dressing. It is now 0800hrs you are the RN
assigned to care for Ruby. When you enter Ruby’s room you notice
that she is in the supine position, pale and responsive.

PATIENT VITAL SIGNS

HR: 88

RR: 24

SpO2: 93% on room air

BP: 102/58

Temp: 36.7 degrees Celsius

QUESTIONS TO CONSIDER WHEN CARING FOR A PATIENT WITH
A PCA

What is the most likely cause of Ruby’s current condition?

What action is required by you?
Is this a medical emergency?

LAB ACTIVITIES

• Nursing assessment
• Irrigation wound dressing
• PCA Observations
• Write nursing report
• Update Multidisciplinary Careplan (MDCP)