To ensure the sharing of patient data is pertinent tothe patient and useful to nurses and members of the health careteam, there should be an organized, logical order in the way theinformation is documented.
Read the patient information below and arrange theinformation into subjective and objective data. Include this inyour discussion post along with answers to the questions thatfollow.
Alert and oriented, restless, seems uncomfortable, shortof breath on exertion, # 22 angio, saline well in left wrist,flushed with 3 mL of NS once, BP 180/96, RR 26 and shallow,temperature 98° F (36.7°C), AP HR 96 irregularly irregular; reportspain of 7 using a 0-10 verbal pain scale in lower extremities,patient states âI need my pain medication now, the pain is gettingout of controlâ, 2 gm Sodium diet, 100 mL fluid with meds, patientconsumed all of breakfast and fluids on his tray, allergic toLipitor, transfer with one assist and walker x1, anti-embolismstockings when OOB, patient refused to get OOB (said âI just donâtfeel like it nowâ), oxygen saturation 91% on 3 liters via N/C,breath sounds diminished bilaterally, cannot lie flat withoutbecoming SOB, weight elevated 8 lbs today, severe edema in his legsto his knees, report oxygen saturation below 90% to the physician,skin on bilateral lower extremities is intact, dry, edematous,shiny, cool to touch with intact sensation bilaterally,medications: furosemide 80 mg, potassium chloride 40mEq daily,amlodipine 10 mg, pravastatin 40 mg, metoprolol 50 mg, lisinopril40 mg all taken at 0900 by mouth without problem.
Use the scenario information above to address thediscussion points by taking the information that was read in theassignments and applying it to the scenario.
Compare and contrast the advantages and disadvantages ofSOAP method of documentation.
Discuss why it is necessary for all members of thehealth care team to use the same method to document a patientâshealth status.
Using nursing judgment develop a diagnosis statement forthe patient above which includes one NANDA-I diagnosis, an etiologyand the defining characteristics (nursing diagnosis + related to +as evidenced by).
Identify the data cluster (grouping of significant datathat points to the existence of the patient health problem) used toselect the nursing diagnosis.
Identify one patient outcome (realistic, measureable andcontains a time frame).
List at least four (4) interventions the RN wouldimplement. Label each intervention as independent nursing action(intervention) or interdependent nursing action(intervention).
Provide a rationale for each action(intervention)
To ensure the sharing of patient data is pertinent tothe patient and useful to nurses and members of the health careteam, there should be an organized, logical order in the way theinformation is documented.
Read the patient information below and arrange theinformation into subjective and objective data. Include this inyour discussion post along with answers to the questions thatfollow.
Alert and oriented, restless, seems uncomfortable, shortof breath on exertion, # 22 angio, saline well in left wrist,flushed with 3 mL of NS once, BP 180/96, RR 26 and shallow,temperature 98° F (36.7°C), AP HR 96 irregularly irregular; reportspain of 7 using a 0-10 verbal pain scale in lower extremities,patient states âI need my pain medication now, the pain is gettingout of controlâ, 2 gm Sodium diet, 100 mL fluid with meds, patientconsumed all of breakfast and fluids on his tray, allergic toLipitor, transfer with one assist and walker x1, anti-embolismstockings when OOB, patient refused to get OOB (said âI just donâtfeel like it nowâ), oxygen saturation 91% on 3 liters via N/C,breath sounds diminished bilaterally, cannot lie flat withoutbecoming SOB, weight elevated 8 lbs today, severe edema in his legsto his knees, report oxygen saturation below 90% to the physician,skin on bilateral lower extremities is intact, dry, edematous,shiny, cool to touch with intact sensation bilaterally,medications: furosemide 80 mg, potassium chloride 40mEq daily,amlodipine 10 mg, pravastatin 40 mg, metoprolol 50 mg, lisinopril40 mg all taken at 0900 by mouth without problem.
Use the scenario information above to address thediscussion points by taking the information that was read in theassignments and applying it to the scenario.
Compare and contrast the advantages and disadvantages ofSOAP method of documentation.
Discuss why it is necessary for all members of thehealth care team to use the same method to document a patientâshealth status.
Using nursing judgment develop a diagnosis statement forthe patient above which includes one NANDA-I diagnosis, an etiologyand the defining characteristics (nursing diagnosis + related to +as evidenced by).
Identify the data cluster (grouping of significant datathat points to the existence of the patient health problem) used toselect the nursing diagnosis.
Identify one patient outcome (realistic, measureable andcontains a time frame).
List at least four (4) interventions the RN wouldimplement. Label each intervention as independent nursing action(intervention) or interdependent nursing action(intervention).
Provide a rationale for each action(intervention)
