Question

This is a very important assignment, I need help with it is either failing or passing assignment please if you are not sure about your answer do not respond, I need answers typed, please.

Learning Outcomes

By the end of this assignment, the student will:

Document focused body system assessments correctly and accurately. (35% of grade)

Document interventions correctly and accurately. (35% of grade)

Demonstrate integration of clinical reasoning within documentation. (15% of grade)

Demonstrate accurate implementation of the nursing process within documentation. (15% of grade)

Grading Rubric

Students will be graded based upon the following rubric:

Criteria	Unacceptable (0%)	Poor (25%)	Acceptable (50%)	Good (75%)	Excellent (100%)
Documents focused body system assessments correctly and accurately.	No body system assessments are correctly and accurately documented.	Few body system assessments are correctly and accurately documented.	Some body system assessments are correctly and accurately documented.	Most body system assessments are correctly and accurately documented.	All body system assessments are correctly and accurately documented.
Documents interventions correctly and accurately.	No interventions are correctly and accurately documented.	Few interventions are correctly and accurately documented.	Some interventions are correctly and accurately documented.	Most interventions are correctly and accurately documented.	All interventions are correctly and accurately documented.
Demonstrates integration of clinical reasoning within documentation.	No clinical reasoning present within documentation.	Clinical reasoning is difficult to assess within documentation.	Limited clinical reasoning present within documentation.	Some clinical reasoning present within documentation.	Frequent clinical reasoning present within documentation.
Demonstrates accurate implementation of the nursing process within documentation.	No implementation of the nursing process present within documentation.	Accurate use of the nursing process is difficult to assess within documentation.	Accurate use of the nursing process is limited within documentation.	Use of the nursing process in documentation is mostly accurately.	Accurate use of the nursing process is exemplar within documentation.

Instructions: You are a registered nurse working on a rehabilitation unit. You took care of Mr. Alan Moore today. You worked from 0700 to 1500. It is the end of your shift, and the current time is 1500.

In the patient’s electronic health record, please chart the following on Mr. Moore based on the scenario below. Remember to keep in mind the shift you are working. Only chart the things that happened from 0700 to 1500.

Please chart:

At 0900, two priority nursing diagnoses (1 actual and 1 risk), including:

The assessment findings that led you to choose the diagnosis

The diagnosis itself (diagnosis, etiology, and evidence as applicable)

Two outcomes for each nursing diagnosis statement you have chosen

Three interventions for each nursing diagnosis statement you have chosen

(Nursing diagnoses are found under “Care Plan”)

An assessment of the following areas:

Morse Fall Risk at 0900 (“Flowsheets” à “Assessment” à “Morse Fall Scale”)

Incision at 0900 (“Flowsheets” à “Wounds/Incisions/Ostomies” à “Add Incision”)

GI at 0900 (“Flowsheets” à “Assessment” à “Gastrointestinal”)

GU at 0900 (“Flowsheets” à “Assessment” à “Genitourinary”)

Pain at 0930 (“Flowsheets” à “Assessment” à “Pain Assessment”)

Intake and output for your 0700 to 1500 shift (“Flowsheets” à “Intake and Output”)

Vital signs for your 0700 to 1500 shift (“Flowsheets” à “Vital Signs”)

Medications administered during your 0700 to 1500 shift (document under “MAR”) – Chart these medications for the date of April 28^th (EHR will let you document in the future).

Patient Scenario:

Patient: Moore, Alan

Age: 64 years (birthdate is today)

Medical Record #: 361476

Height: 5’ 9”   Weight: 379 pounds BMI: 56

Allergies: NKA

History of Present Illness (HPI): Mr. Moore had gastric bypass surgery approximately one week ago. Post-operatively, Mr. Moore developed nausea and vomiting and was unable to tolerate anything PO for 4 days. Mr. Moore subsequently developed weakness and was unable to be discharged home. He was admitted to the rehabilitation facility to build up strength before going home.

Mr. Moore was doing well until he began to experience intense abdominal pain and nausea again last week. He was readmitted to the hospital 2 days ago to be evaluated for post-op complications.

Past Medical History (PMH): Diabetes, hypertension, sleep apnea and dyslipidemia.

Patient Information:

Mr. Moore is alert and oriented x3. His vital signs at 0900 were: 38.5, 102, 22, 144/80. His oxygen saturation was 93% RA. His lungs sounds were diminished in the bases. His skin was cool and mostly moist.

At 0930, Mr. Moore complained of incisional pain, stating, “This is awful. I hurt so much. I would have skipped the surgery if I knew how much pain I’d be in. If I don’t move, it feels better. I keep praying for relief.” You noticed that Mr. Moore splints his abdomen with any movement. When asked to rate his pain a scale of 0 to 10, he told you it was a 9. He described the pain as sharp and stabbing. The pain had been happening for 20 minutes and started after he coughed. You administered 10 mg of PO oxycodone to Mr. Moore at 0930.

Mr. Moore had no PO intake yesterday due to nausea and vomiting. Today, he has been able to tolerate his full liquid diet. At 0800, he drank 240 ml of water and 240 ml of diet ginger ale without nausea. At 1200, he received a lunch tray with 240 ml of pudding and 240 ml of diet ginger ale; he ate and drank the entire tray. The tray contained 20 carbs.

His finger stick blood glucose at 0800 was 150 mg/dl, and at 1200 it was 176 mg/dl. Mr. Moore had hypoactive bowel sounds in all four quadrants. His abdomen is distended and soft in all four quadrants. He reported having flatus, but no BM yet. His indwelling catheter was removed at 0600. He voided 400 ml clear yellow urine at 0900, and 350 ml of clear yellow urine at 1400.

He had a dry sterile dressing (DSD) on his midline abdominal incisional wound. The edges of the wound were approximated with staples. The wound was 13 centimeters in length. The dressing was clear and dry, with no drainage coming out of the wound. The skin surrounding the wound was moist and cool.

Mr. Moore had two JP drains, one in the left lower quadrant and one in the right upper quadrant. During your shift, you emptied the JP drains every 4 hours. Each time they were emptied, JP #1 put out 20 ml of serosanguineous fluid and JP #2 put out 15 ml of serosanguinous fluid. You first emptied the drains at 1030. He had an IV in place infusing LR at 85 ml/hr. This was infusing at the start of your shift at 0700.

His VS were repeated at 1200: 38.7, 110, 22, 142/82. Oxygen saturation was 94% RA. Due to the post-op pain, he didn’t ambulate very much today. When he did ambulate, he required a walker and had a shuffled gate. Mr. Moore has never fallen while walking.

Mr. Moore’s Current Medication Orders:

1000 ml, LR, IV, 85 ml/hr, continuous

The IV pump rang that the bag was empty at 1100. You hung a new bag at this time.

Oxycodone, 5 to 10 mg, PO, q4hr PRN for moderate to severe pain

Cefazolin, 500 mg in 100 ml NS, IV, q8h

Scheduled times for administration: 0600, 1400, 2200

Heparin, 7500 units, SQ, BID

Scheduled times for administration: 0900, 2100

Ondansetron, IV, 4 mg, q8h PRN nausea

Hydrochlorothiazide, 25 mg, PO, daily

Scheduled time for administration: 0900

Norvasc, 5 mg, PO, BID

Scheduled times for administration: 0900, 2100

Simvastatin, 40 mg, PO, daily

Scheduled time for administration: 2100

Regular insulin for prandial coverage, SQ, with meals:

1 unit for every 10 grams of carbs consumed

Hold if patient NPO or consuming under 10 grams of carbs

     

Regular insulin for correctional coverage, SQ, with meals:

Hold if glucose less than 180 mg/dl

2 units for glucose of 180 - 210 mg/dl

4 units for glucose of 211 - 240 mg/dl

6 units for glucose of 241 - 300 mg/dl

If glucose is greater than 300 mg/dl, call provider

Answer 1

$\rightarrow$ Nursing Diagnosis at 0900 :

1. Ineffective breathing pattern related to obesity /and or the present illness as evidenced by altered lung sounds, coolness, and moistness of the skin

2. Risk for constipation related to pain medication use decreased fluid intake and decreased mobility as evidenced by no stools, hypoactive bowel sounds, the presence of flatus and distended abdomen.

1.

Nursing Diagnosis	Desired outcomes	Interventions
Ineffective breathing pattern pattern related to obesity/and or the present illness as evidenced by altered lung sounds, coolness and the moistness of the skin	*Patient maintains an effective breathing pattern and maintains the saturation levels between 94-100% *When patient carries out ADL's, breathing patterns remains normal	*Assess for any temporary cessation of breathing, especially during sleep *Assess for any shortness of breath and note for any signs of dyspnea *Utilize pulse oximetry to check oxygen saturation and pulse

2.

Nursing Diagnosis	Desired outcomes	Interventions
Risk for constipation related to pain medication use decreased fluid intake and decreased mobility as evidenced by no stools, hypoactive bowel sounds, the presence of flatus and distended abdomen.	*Patient maintains the passage of soft, formed stool at a frequency perceived as normal by the patient. *Patient identifies measures that prevent or treat constipation	*Assess the patient's activity level *Classify current medications usage that may lead to constipation *Consider the degree to which the patient responds to the urge to defecate

$\rightarrow$ Morse Fall Scale at 0900

Item	Item Score	Patient Score
History of falling	No 0 Yes 25	0
Secondary Diagnosis (More than one diagnosis)	No 0 Yes 15	15
Ambulatory Aid	None, bed rest, Nurse assist 0 crutches/cane/walker 15 Furniture 30	15
Intravenous therapy/Heparin lock	No 0 Yes 20	0 (SQ admin)
Gait	Normal/Bed rest/Wheelchair 0 Weak 10 Impaired 20	20
Mental Status	Oriented to own ability 0 Overestimates/Forget limitations 15	0
Total Score		50

Here Mr.Moore, Morse Fall Scale Assessment is Total Score obtained is 50 (that means it is >45) indicates High Risk

$\rightarrow$ Incision at 0900

Mr, Moore had a dry sterile dressing on his midline abdominal incisional wound>The edges of the wound are approximated by staples and the wound has 13 centimeters in length. The dressing was clear and dry with no oozing from the wound and skin around the wound was found to be moist and cool indicates, there is no evidence or signs of infection

He had two JP drains one in the left lower quadrant and one in the right upper quadrant presents with serosanguinous fluid. This indicates that the discharge is normal and is in the early stages of healing, as the blood is presented in small amounts.

$\rightarrow$ GI at 0900

Mr. Moore able to tolerate with the liquid diet had hypoactive bowel sounds in all four quadrants with distended and soft abdomen with complaints of flatus but no bowel movements yet due to limited activity, pain and effects of medications

$\rightarrow$ GU at 0900

At present, there is no indwelling catheter it was already removed. At 0900 he voided 400ml of clear yellow urine indicates that the Mr.Moore GU system is tolerated with the present situation and is functioning well.

$\rightarrow$ Pain Assessment at 0930

At 0930 after he coughed there started an incisional pain and stating it as sever and rating it as 9.To bearing the pain Mr.Moore splints his abdomen with any movement. The type of pain is sharp and stabbing to Mr.Moore and is happening for 20 minutes.

Administered oxycodone 10 mg PO to Mr.Moore, in the medication order it is mentioned as PRN for moderate to severe pain.

$\rightarrow$ Intake and output of 0700 to 1500 shift

*Total oral intake: 960ml (Includes water, ginger ale, and pudding)

*Total IV fluids administered: 680 mL (LR 85ml/hr is infusing)

Thus overall intake of fluid is: 1640ml

*output as urine : 750ml (urine)

*Output as JP drain: 70ml of serosanguinous fluid as drain 2 times (1030 and 1430)

Thus the total output is: 820 ml (includes urine and JP drain)

$\rightarrow$ Vital signs for 0700 to1500 shift

Vital signs at 0900 :

Temp:38.5^oc

Pulse :102bpm

Resp :22b/m

B.P :144/80mmHg

Oxygen saturation: 93%

Vital signs at 1200:

Temp:38.7^oc

Pulse: 110bpm

Resp :22b/m

Here the patient is showing the variation in temperature(rise in body temperature) indicates MR. Moore is having the fever

B.P :142/82mmHg

Oxygen saturation: 94% RA

$\rightarrow$ Medications Administered :

Name: Moore Alan Age: 64 Y Sex: Male

Chief complaints: Intense abdominal pain and Nausea

Admitting Diagnosis: Evaluate for the post-op complications of gastric bypass surgery

Diet: liquid: diet

Case NO #:361476

Height :5; 9" weight :379 Pounds   

Date of birth: 28-4-1954

Date	Treatment	Medications	IVF
28-04-2018	*TPR q shift *Vital signs 4 the hourly *Refer for the pain, fluid status and other unusualities	*Oxycodone 5 to 10 mg PO,q4hr/PRN for moderate to severe pain *Cefazolin 500mg in 100ml NS,IV q8h *Heparin 7500 units SQ, BID *Ondansetron IV,4mg,q8h, PRN nausea *Hydrochlorothiazide 25mg, PO, Daily *Norvasc ,5mg,PO,BID *Regular insulin for Prandial Coverage, SQ with meals: 1 unit for every 10 grams of carbs consumed *Regular insulin for correctional coverage, SQ with meals : # Hold if glucose is less than 180mg/dl	*LR at 85 ml/hr