Surgical Case 5: Lloyd Bennett

Documentation Assignments

1. Document your focused postoperative assessment for Lloyd Bennett.

 For the post-operative assessment patient was A&O x 4, denied any pain. Lung
sounds were clear and equal bilaterally. Auscultation of heart had regular rate and
rhythm; no murmurs noted. The respirations were 17 breaths per minute with chest
rising equally. There was no neurovascular compromise, or dislocation of prosthesis.
Also, there were no signs or symptoms of deep vein thromboses or infection.
However, signs of hemorrhage and bleeding were noted by severe decrease in
hemoglobin and hematocrit after surgery.

2. Document Lloyd Bennett’s allergies in his chart.

 Patient’s chart did not state any allergies and upon assessment questionings patient
denied any allergies.

3. Document Lloyd Bennett’s vital signs during the transfusion reaction.

 During transfusion reaction patient’s vital signs were as following:
 Heart rate 97 beats per minute.
 Blood pressure: 110/72 mmHg
 Temperature: 99-degree F
 Respirations: 19 breaths per minute

4. Document the priority nursing actions completed during the transfusion reaction.
1. Stop transfusion immediately.
2. Replace tubing containing blood with new tubing primed with NS, DO NOT flush IV
tubing containing blood.
3. Continue to maintain IV access.
4. Check Vital Signs.
5. Notify provider while staying with patient.
6. Verify the PT ID matches the blood label.
7. Treat symptoms.
8. Notify the blood lab as per hospital policy

5. Identify and document key nursing diagnoses for Lloyd Bennett.

 Risk for constipation
 Risk for imbalanced temperature
 Risk for falls
 Impaired physical mobility
 Risk for infection
 Risk for deep vein thrombosis.
 Risk for decreased cardiac output.

© Wolters Kluwer Health | Lippincott Williams & Wilkins

6. Referring to your feedback log, document the nursing care you provided.
 Performed head to toe assessment
 Attached non-invasive continuous blood pressure cuff.
 Monitored vital signs every 4 hours.
 Educated patient on signs and symptoms of transfusion reaction.
 Transfused two unit packed red blood cells.
 Assessed for vital signs after starting transfusion.
 Stopped the transfusion when patient developed back pain, and initiated infusion
of 100 mL/hr Normal saline.
 Obtained urine specimen and venous sample.
 Assessed for patient’s pain and temperature post transfusion reaction.

© Wolters Kluwer Health | Lippincott Williams & Wilkins