브이심(v-Sim) Marilyn Hughes 5/6단계 답변 (구획증후군)

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목차

[1] Documentation Assignments
1. Document a comprehensive pain assessment for Marilyn Hughes.
2. Document Marilyn Hughes’ neurovascular assessment.
3. Document the changes in Marilyn Hughes’ vital signs.
4. Identify and document key nursing priorities for Marilyn Hughes.
5. Referring to your feedback log, document the nursing care you provided and Marilyn Hughes’ response to this care.

[2] Guided Reflection Questions
1. How did the scenario make you feel?
2. How would you recognise that Marilyn Hughes’ condition was deteriorating?
3. What interventions exist to alleviate compartment syndrome, and what assessments indicate improved perfusion to the extremity?
4. Why is it important to maintain the limb at heart level versus elevating it above heart level?
5. What could have happened in this scenario if Marilyn Hughes’ condition was not treated expediently?
6. What key elements would you include in the handover report for this patient? Consider the ISBAR (introduction, situation, background, assessment, recommendation) format.
7. What would you do differently if you were to repeat this scenario? How would your patient care change?

본문내용

1. Document a comprehensive pain assessment for Marilyn Hughes.
-환자 기록지에 환자가 고통척도 4라고 응답한 것이 기록되어 있다.
-그녀에게 고통이 있냐고 질문했을 때 “네”라고 대답했다.
-고통이 0부터 10중에 어느 정도냐고 질문했을 때 “8정도 된다”고 대답했다.
-“다리가 욱신거리고 타는듯한 느낌이 들어요”라고 말했다.
-환자의 다리를 사정했을 때 창백하고 pedal pulse가 느껴지지 않는 등 구획증후군의 증상이 나타났다. 이와 함께 환자가 “붕대가 꽉 끼는 것 같아요”라고 말했다.

2. Document Marilyn Hughes’ neurovascular assessment.
-환자의 왼쪽 다리 신경혈관을 사정했을 때 이는 구획증후군임을 알 수 있었다.

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