Christopher Parrish
Documentation Assignments
1. Document your focused gastrointestinal and dietary assessment of Christopher Parrish.
.
2. Document two nursing diagnoses for this patient.
3. Document your priorit
...
Christopher Parrish
Documentation Assignments
1. Document your focused gastrointestinal and dietary assessment of Christopher Parrish.
.
2. Document two nursing diagnoses for this patient.
3. Document your priorities for care of this patient.
4. Describe the age-related considerations you will use when caring for Christopher Parrish.
5. Referring to your feedback log, document the nursing care, including patient education about nutritional needs and therapy, which you provided to Christopher Parrish. Include his response.
You arrived at the patient's side.
0:00 You reviewed the patient information. 0:00 You reviewed the patient log.
0:00 You reviewed the diagnostics.
0:00 You reviewed the clinical observations. 0:00 You reviewed the MAR.
0:00 You reviewed the orders.
0:00 You reviewed the intake and output.
0:05 You washed your hands. To maintain patient safety, it is important to wash your hands as soon as you enter the room.
0:10 Patient status - ECG: Sinus rhythm. Heart rate: 81. Pulse: Present. Blood pressure: 123/73 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 97%. Temp: 99 F (37.3 C)
1:10 Patient status - ECG: Sinus rhythm. Heart rate: 82. Pulse: Present. Blood pressure: 121/72 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 97%. Temp: 99 F (37.2 C)
1:17 You introduced yourself. This was reasonable.
1:32 You identified the patient. To maintain patient safety, it is important that you quickly identify the patient.
1:41 You asked if the patient was <Allergy>allergic<> to anything. He replied: 'No, I am not allergic to anything.'
1:50 You asked the patient if he had any pain. He replied: 'No, I don't have any pain.'
2:06 You asked the patient if he had taken his medication, if any. He replied: 'I didn't take my meds yet.'
2:10 Patient status - ECG: Sinus rhythm. Heart rate: 82. Pulse: Present. Blood pressure: 121/72 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 97%. Temp: 99 F (37.2 C)
2:11 You asked the patient what medication he was taking, if any. He replied: 'Yes, I take enzymes for digestion.'
2:27 You asked the patient how he felt. He replied: 'I am tired.'
2:31 You asked: What were you doing when the symptoms started? He replied: 'Nothing special.'
2:38 You asked the patient if he had had anything to eat or drink today. He replied: 'No, I haven't eaten anything yet today.'
2:45 You asked the patient if he felt nauseated. He replied: 'No. I don't have any nausea.'
2:56 You asked the patient: Do you follow a special diet prescribed by your doctor? He replied: 'Yes. A high-fat, high-calorie diet.'
3:04 You asked the patient: Do you use any vitamins or food supplements? He replied: 'Yes, I do take special vitamins. I have to take extra vitamins because of my CF. I don't take any supplements.'
3:10 Patient status - ECG: Sinus rhythm. Heart rate: 82. Pulse: Present. Blood pressure: 122/73 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 97%. Temp: 99 F (37.2 C)
3:16 You asked the patient: Are you getting the meals you need on a daily basis? He replied: 'Well, I am in college and sometimes I may not make it to the cafeteria in time. That has happened a few times. I have snacks in my room, but they don't really replace a meal.'
3:33 You asked the patient: How many bowel movements do you have every day and what is the consistency? He replied: 'I usually have one or two, and they're mostly formed but soft.'
4:06 You looked for normal breathing. He is breathing at 12 breaths per minute. The chest is moving equally.
4:10 Patient status - ECG: Sinus rhythm. Heart rate: 82. Pulse: Present. Blood pressure: 121/72 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 97%. Temp: 99 F (37.2 C)
4:34 You attached the <Pulseoximeter>pulse oximeter.<> It is a good idea to monitor the saturation and pulse here. This will allow you to reassess the patient continuously.
4:46 You checked the radial pulse. The pulse is strong, 85 per minute, and regular. It is correct to assess the patient's vital signs.
5:09 You checked the <Temperature>temperature<> at the ear. The temperature was 99 F (37.2 C).
5:10 Patient status - ECG: Sinus rhythm. Heart rate: 83. Pulse: Present. Blood pressure: 121/72 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
5:31 You measured the <Bloodpressure>blood pressure<> at 122/72 mm Hg. It is appropriate to monitor the patient by measuring the blood pressure.
6:10 Patient status - ECG: Sinus rhythm. Heart rate: 83. Pulse: Present. Blood pressure: 121/73 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
6:14 You listened to the lungs of the patient. The breath sounds are clear and equal bilaterally.
6:36 You listened to the heart of the patient. This is reasonable. There were regular heart sounds without murmurs.
7:03 You listened to the abdomen of the patient. Normal bowel sounds were heard.
7:10 Patient status - ECG: Sinus rhythm. Heart rate: 83. Pulse: Present. Blood pressure: 118/71 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
7:18 You assisted the patient into a sitting position.
7:43 You checked the placement of the nasogastric tube. This was reasonable. 8:08 You aspirated on the nasogastric tube. This was reasonable.
You should have used clean gloves during this procedure.
8:10 Patient status - ECG: Sinus rhythm. Heart rate: 83. Pulse: Present. Blood pressure: 119/71 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
8:30 You flushed the nasogastric tube. This was reasonable.
8:52 You compared the medication label with MAR. This was reasonable.
9:06 A 5-tablet dose of pancrelipase was given orally. It is important to use the basic rights of medication administration to ensure proper drug therapy. This was indicated by order.
9:10 Patient status - ECG: Sinus rhythm. Heart rate: 83. Pulse: Present. Blood pressure: 117/69 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
9:15 You put on gloves.
9:49 You compared the medication label with MAR. This was reasonable.
9:59 You started a 480 mL tube feeding of fluid nutrition 1.5 kCal/mL at 60 mL/hr. This was indicated by order.
10:10 Patient status - ECG: Sinus rhythm. Heart rate: 83. Pulse: Present. Blood pressure: 116/69 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
10:13 You removed the gloves. 10:19 You washed your hands.
11:10 Patient status - ECG: Sinus rhythm. Heart rate: 84. Pulse: Present. Blood pressure: 118/71 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
11:48 You educated the patient about medication.
12:10 Patient status - ECG: Sinus rhythm. Heart rate: 84. Pulse: Present. Blood pressure: 118/70 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
12:12 You educated the patient about positioning. 12:30 You educated the patient about risk of aspiration.
13:02 You educated the patient about tube feeding. This was reasonable.
13:10 Patient status - ECG: Sinus rhythm. Heart rate: 84. Pulse: Present. Blood pressure: 119/71 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
13:55 You educated the patient about activities, safety, and fall risk.
14:10 Patient status - ECG: Sinus rhythm. Heart rate: 84. Pulse: Present. Blood pressure: 118/70 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
14:23 You educated the patient about body mass index. 15:03 You educated the patient about diagnostics.
15:10 Patient status - ECG: Sinus rhythm. Heart rate: 84. Pulse: Present. Blood pressure: 116/70 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
15:43 You educated the patient about diet. This was reasonable.
16:10 Patient status - ECG: Sinus rhythm. Heart rate: 84. Pulse: Present. Blood pressure: 116/70 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
16:16 You educated the patient about intake and output.
17:10 Patient status - ECG: Sinus rhythm. Heart rate: 84. Pulse: Present. Blood pressure: 117/70 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37.2 C)
17:40 You asked the patient if he felt better. He replied: 'No, it's the same.'
17:50 You asked the patient if he felt nauseated. He replied: 'No. I don't have any nausea.'
17:55 You asked the patient: Can I get you some water? He replied: 'No, thank you.'
17:58 A patient handoff was performed.
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