Michele Horton

Sara Lin

Documentation Assignments

1. Document your focused pain assessment of Sara Lin.

I asked if Sara Lin was in pain, and asked her to rate her pain on a scale of 0-10. She
responded with a 6 at first. About 20 minutes after I administered pain medication, she
responded to the same question with a 1.
2. Document your priorities for care of this patient.
The priorities of care for Sara Lin were pain management, education, and preparation for
discharge.
3. Document two nursing diagnoses for this patient.
Knowledge deficient about what she could do/not do when she got home as evidenced by
her asking about restrictions/instructions for when she got home.
Acute pain due to being post-surgical as evidenced by her verbalizing her pain at a 6 on a
0-10 scale.
4. Document patient education regarding pain management for this patient.
Educated Sara Lin about her two pain medications – Acetaminophen 325 mg and
Oxycodone 5 mg that are to be taken every 4 hours. I explained her pain management
would be better and more thorough if she sticks to the schedule and doesn’t let the pain
get out of control. I also educated her about discontinuing the Oxycodone when her pain
lessens due to the chance of dependency with that drug.
5. Referring to your feedback log, document the nursing care you provided to Sara Lin and
her response.
I assessed Sara’s vital signs as well as her pain. I administered pain medication, as well
as her antibiotic. I assessed her pain about 20 minutes after administering medication to
find that she had experienced relief of her pain. I asked her to use the incentive
spirometer and educated her on its use. I assessed her dressing and found it was dry and
intact.

From vSim for Nursing | Fundamentals. © Wolters Kluwer