Nursing Question: The community health RN is caring for a family with a child wh

Question

Nursing Question:

The community health RN is caring for a family with a child who has significant developmental delays. The child is 9-years-old and exhibits the development of a 6-month old infant. She can move her extremities spontaneously, hold her head up and cry out occasionally. She has a gastrostomy tube for her medications and she receives continuous tube feeding via pump. She was discharged 2 days ago after a 5-day hospitalization for failure to thrive. During the hospital stay, the child’s tube feeding formula was adjusted to meet her growing needs. The community health RN is monitoring the child after discharge, following up on the child’s weight and the parent’s knowledge of the new feeding formula type, amount, and schedule. Today the child weighs 64 pounds. The child’s current weight represents a 2 pound weight gain since hospital admission.

The RN has chosen the NANDA-I nursing diagnosis of Ineffective health management r/t insufficient knowledge of expected growth and calorie requirements AEB parent states, “I thought the same tube feeding would be enough calories for a long time, I don’t know how to tell if the feeding should be adjusted.”

·         Compare and contrast narrative documentation with SOAP/SOAPIE/SOAPIER- style documentation.

·         Create a documentation entry to describe the community health nurse’s first visit based on this scenario using SOAP/ SOAPIE/SOAPIER-style documentation. Students may embellish the scenario with additional patient information or parent’s response to teaching if desired.

Explanation / Answer

answers:

SOAP Documentation: It is a problem oriented techniques whereby the nurse identifies and list the patients health concern. These documentation contains following headings:

S= subjective data , O = objective data , A = Assement , P = plan , I = Interventions , R = revision

SOAP format : also called SOAPIE/SOAPIER

                         format in 4 parts : Problem list , Initial plan, Progess notes, Discharge summary

SOAP Progress Report: This is where you record the SOAP(IER) information. As rule, you enter note for each current problem every 24 hrs or when patients conditions changes.

PIE format : Problem intervention Evaluation

                     Requires keeping a daily assesment record and progress notes, eliminates the need for a separate care plan and provides a nursing focused rather than medical focus reccord .

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