Documentation for Suture and Staple Removal
ADNG 1050 Foundations of Nursing Skills
Scenario:
26-year-old male who has returned to the clinic for suture removal.
šļø Documentation
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To complete: Upload this document to your computer & fill it out electronically (directly into the assignment)
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To turn it in: Re-upload it to the correct file/drop box in D2L.
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1. Write a
DARP note including: (Erase below information under each heading and type as if you are writing a nursing note)
D: Data
Ā· Baseline vital signs
Ā· Initial wound assessment
Ā· Reason for suture removal
A: Action
Ā· State that education was given
Ā· What was the procedure you performed
R: Response/Results
Ā· Patientās tolerance to procedure
Ā· Reassessment of site and/or VS
P: Plan
Ā· Discharge education
Ā· Follow-up only if signs of infection or complications
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2. Patient Education (Write as a Script) Keep short and to the point.
Ā· Describe the skill being performed in simple terms.
Ā· Explain the need for the skill to be done.
Ā· Educate on what they can expect during the skill and after the skill is complete. You will experience pressure during the insertion part. Remember to bear down.
Ā· Provide any other valuable knowledge to patient that is relevant to the skill being done.
š 3. National Patient Safety Goal (NPSG) Choose 1 priority NPSG that is relevant to this scenario and tell us why in 1 paragraph.
NPSG Chosen:
Why It Matters:
š 4. Nursing Diagnosis & Care Plan
ā 3-Part Nursing Diagnosis:
Instructor example
: Anxiety
related to unfamiliar medical procedures and potential pain
as evidenced by patient asking multiple questions and expressing nervousness before suture removal.
Student nursing diagnosis:
šÆ 5. SMART Goal:
Instructor example
: Patient will verbalize understanding of the procedure and report anxiety level of 3 or less (on a 0ā10 scale) prior to the start of the suture removal today.
Student SMART goal:
𩹠List:
Ā·
2 Interventions to accomplish this goal
Ā· Rationale for each intervention
Ā· Evaluation for each intervention
1. Intervention:
Ā· Rationale:
Ā· Evaluation:
2. Intervention:
Ā· Rationale:
Ā· Evaluation:
š„Video Review: IF you have any limited comments (āI would haveā¦.ā OR āI forgot toā¦ā) Please add below.