Using the assigned readings and information from the literature, compose a response to the following:
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 ofSOAPmethod 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,measureableand 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)
Provide a reference for each of your rationales
In your responses to your peers' posts provide constructive and insightful comments that go beyond that of agree or disagree.
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You are required to post your initial response to the discussion question by Wednesday at 11:59 PM (EST) of the week it is due. Your initial post cannot be a response to another student's post. Students who do not submit their response to the discussion questions as noted above will have 10 points deducted from their discussion question grade for that week.
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