To ensure the sharing of patient data is pertinent to the patient and useful to
ID: 50991 • Letter: T
Question
To ensure the sharing of patient data is pertinent to the patient and useful to nurses and members of the health care team, there should be an organized, logical order in the way the information is documented.
Read the patient information below and arrange the information into subjective and objective data. Include this in your discussion post along with answers to the questions that follow.
Alert and oriented, restless, seems uncomfortable, short of 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; reports pain of 7 using a 0-10 verbal pain scale in lower extremities, patient states “I need my pain medication now, the pain is getting out of control”, 2 gm Sodium diet, 100 mL fluid with meds, patient consumed all of breakfast and fluids on his tray, allergic to Lipitor, transfer with one assist and walker x1, anti-embolism stockings when OOB, patient refused to get OOB (said “I just don’t feel like it now”), oxygen saturation 91% on 3 liters via N/C, breath sounds diminished bilaterally, cannot lie flat without becoming SOB, weight elevated 8 lbs today, severe edema in his legs to 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, lisinopril 40 mg all taken at 0900 by mouth without problem.
Use the scenario information above to address the discussion points by taking the information that was read in the assignments and applying it to the scenario.
Compare and contrast the advantages and disadvantages of SOAP method of documentation.
Discuss why it is necessary for all members of the health care team to use the same method to document a patient’s health status.
Using nursing judgment develop a diagnosis statement for the patient above which includes one NANDA-I diagnosis, an etiology and the defining characteristics (nursing diagnosis + related to + as evidenced by).
Identify the data cluster (grouping of significant data that points to the existence of the patient health problem) used to select the nursing diagnosis.
Identify one patient outcome (realistic, measureable and contains a time frame).
List at least four (4) interventions the RN would implement. Label each intervention as independent nursing action (intervention) or interdependent nursing action (intervention).
Provide a rationale for each action (intervention)
Explanation / Answer
Subjective data of the patient:
reports pain of 7 using a 0-10 verbal pain scale in lower extremities, patient states “I need my pain medication now, the pain is getting out of control” and patient refused to get OOB (said “I just don’t feel like it now”).
Objective data of the patient:
Patient's vital signs are Alert and oriented, restless, uncomfortable, short of breath on exertion, # 22 angio, saline well in left wrist, BP 180/96, RR 26 and shallow, temperature 98° F (36.7°C), AP HR 96 irregularly irregular; reports pain of 7 using a 0-10 verbal pain scale in lower extremities,oxygen saturation 91% on 3 liters via N/C, breath sounds diminished bilaterally.
Compare and contrast advantages and disadvantages of SOAP method of documentation:
Advantages of SOAP method:(a)it makes retrieval of information much easier.(b)care is problem focused.(c)the location of the problem at the front of the chart alerts all caregivers.(d)its consistency in the nursing process.
Disadvatages of SOAP method:(a)level of ability & consistency of formats may vary.(b)problem focus may reduce minor problems to be solved.(c)maintaining a neat up to date problem list takes time to review.
Discuss why it is necessary for all members of the health care team to use the same method to document a patient’s health status.
A primary purpose of documentation and recordkeeping systems is to facilitate information flow that supports the continuity, quality, and safety of care.Nursing documentation covers a wide variety of issues, topics, and systems. Researchers, practitioners, and hospital administrators view recordkeeping as an important element leading to continuity of care, safety, quality care, and compliance.Current research indicates that ineffective communication among health care professionals is one of the leading causes of medical errors and patient harm.If the same method of documentation is not maintained it may lead to misflow of the correct information of the under treatment patient and may lead to serious consequences.
Using nursing judgment develop a diagnosis statement for the patient above which includes one NANDA-I diagnosis, an etiology and the defining characteristics (nursing diagnosis + related to + as evidenced by).
Nanda I diagnosis-Impaired motion and acute pain in lower extremities related to fluid accumulation as evidenced by patient's report of pain 7 using a verbal scale of 0-10 in lower limbs,transfer with one assist and walker x1, anti-embolism stockings when OOB, patient refused to get OOB (said “I just don’t feel like it now”), cannot lie flat without becoming SOB,alert and oriented, restless, seems uncomfortable,weight elevated 8 lbs today.
Identify the data cluster (grouping of significant data that points to the existence of the patient health problem) used to select the nursing diagnosis.
-Alert and oriented, restless, seems uncomfortable
-short of breath on exertion, # 22 angio
-BP 180/96, RR 26 and shallow
-reports pain in lower extremities
-transfer with one assist and walker x1
-anti-embolism stockings when OOB, patient refused to get OOB
-breath sounds diminished bilaterally, cannot lie flat without becoming SOB
-weight elevated 8 lbs today, severe edema in his legs to his knees
-temperature 98° F (36.7°C), AP HR 96 irregularly irregular.
-skin on bilateral lower extremities is intact, dry, edematous, shiny.
Identify one patient outcome (realistic, measureable and contains a time frame).
The patient reports pain of 7 using a 0-10 verbal pain scale in lower extremities, patient states “I need my pain medication now, the pain is getting out of control”.
List at least four (4) interventions the RN would implement. Label each intervention as independent nursing action (intervention) or interdependent nursing action (intervention).
(a)Obtaining daily weight(independent nursing action)-Like any liquid, the fluid in the body has weight. The nurse weighs the patient every day using the same scale and during the same time, which is usually in the morning. A weight measurement is a good indicator of how much fluid is in the body when comparing the readings from day to day.
(b)Monitoring intake and output(independent nursing action)-Nurses measure the amounts of fluids going in and out of the body over a period of time. The intake includes the fluid that goes in the body like water,tea,coffee,soups,broths.The output is the fluid that goes out of the body. Urine is the most common type of output the nurse measures. Other examples are the fluids from vomiting, diarrhea, and bleeding.
A healthy person has a fluid balance which is the correct amount of fluid in the body. When the intake is greater than the output, the difference indicates how much excess fluid exists in the body.
(c)Positioning the body(independent nursing action)-Excess fluid in the body can gather in the arms and legs and lead to edema when the limbs are in downward position.
(d)Instruct the individual to avoid made of jersey pants / girdle, knee-high pants, and crossed the lower leg and remained elevated leg exercises whenever possible.(interdependent nursing action).
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