Lab 3

Kelly Francis

Kelly Francis is a 58 year old female who had a complete mastectomy of her R breast after a diagnosis of stage 4 carcinoma. Her surgery was yesterday and you have been told she had a restful night with sedation. Her nursing assessment shows a history of high cholesterol and hypertension both managed by medications. She is supported by her husband of 35 years and her 2 grown children.
Post-operatively she has a Jackson Pratt drain in place and an occlusive dressing on her R side where the breast was removed. She has an IV infusing. She has not been up to ambulate post operatively and her care plan shows that she is to attempt ambulation today.

After reviewing the chart you come in to assess Kelly Francis she is in semi-fowler’s position and her eyes are closed. She appears to be resting quietly.

What are your first steps when meeting Kelly Francis?

 

Once you are able to speak with Kelly Francis you find her to be very soft spoken and tearful. What types of communication techniques would you use/what would you say to Kelly Francis?

 

What are some of issues you feel could be causing Kelly Francis to be tearful and upset?

 

Upon physical examination of Kelly Francis you assess her vital signs to be BP 128/82 P-100, R- 19, T- 37.9 °C . What is your assessment of these vital signs?

 

What other physical observations would you make? Assess Kelly Francis.

 

Note any unusual findings from assessing Kelly Francis, what would be your response to each of the findings.

 

2 hours into your shift you go in to check on Kelly Francis and to get her up into a chair. You find her complaining of a headache and pain from her surgical site. She also states that she is having difficulty focusing with her eyes.

What are your first steps to getting Kelly Francis up and into a chair?

 

What are some reasons Kelly Francis could be complaining of a headache and difficulty focusing?

 

What are your assessments and nursing interventions for Kelly Francis at this time?