Question: Environment: Patient Is Positioned In The Center Of The Bed Patient Has Ace Wrap On Lower Extremity Patient Has Glasses On Over The Bed Table Patient O Patient Is Newly Admitted To The Unit. Lives In Long-term Care Facility. She Presents With A Productive Cough, Facial Grimacing When Coughing, Nonverbal And Demonstrates Discomfort With Movement Of Her …

Environment: Patient is positioned in the center of the bed Patient has ace wrap on lower extremity Patient has glasses on over the bed table Patient o Patient is newly admitted to the unit. Lives in long-term care facility. She presents with a productive cough, facial grimacing when coughing, nonverbal and demonstrates discomfort with movement of her lower right extremity. She has a stage 3 pressure ulceron the right Patient pain level assesses at 5/10 (Faces scale) in the lower right extremity Patient is not an accurate historian Orders Perform a head to toe assessment Implement appropriate nursing intervention as indicated Complete SBAR Perform Pain Assessment