Question

This is a graded discussion: 100 points possible due Jan 27 M2D1: Documenting Patient Care Note: You may not post to this discussion until week 2. 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 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 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 tube for tube feeding type, amount, and schedule. Today the child weighs 50 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 Deficient knowledge r/t change in 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. Initial Discussion Post: Create a narrative note to record this patient's current health state. Discuss why accurate documentation is critical in healthcare. What information is crucial to include in a handoff report? Discuss the role of nursing informatics in this scenario.

Answer 1

Answer :

Q. No. 1. Answer :

The patient current health status :

* the patient is diagnosed with failure to thrive.

* failure to thrive means failure to meet the normal growth of baby. Or failure to maintain normal weight according to age.

* child is 9 years old, but there is a 6 months old characteristics or milestones are showing by child.

* the child molestones are moves her extremities spontaneously, hold her head up and cry out occasionally.

* she is in gastrotomy tube feeding.

* child weight is 50 pounds.

* the registered nurse recognized that the baby gained weight 2 pounds after admission, because of formula feeding.

* that means at the admission time child weight is 48 pounds only.

* now the child is in improving status.

* the same tube feeding may improve the nutritional status of the baby.

* educate the parents how to provide tube feeding with asceptic techniques.

* and preparation of the formula also should be explain to parents.

* daily monitoring of weight of the client.

Q. No 2. Answer :

Accurate documentation is critical in health care because, the information which is provided by the persons or parents it should be accurate, some times they may not provide accurate information to health care professionals.

* according to the parents or attenders information only we need to correlate the client symptoms and need to plan care.

* so the accurate documentation is critical in health care.

Q. No 3. Answer :

* hand off reports are very important to the patient safety.

* through hand off reports accurate and up to date information can available for next shift staff.

* here baby condition like failure to thrive.

* gastrotomy tube feeding.

* formula preparation.

* daily weight checking of baby.

* parents knowledge assessment regarding baby care.

* the daily calories requirement for baby.

These are the crucial to mention in hand off reports.

Q. No 4. Answer :

* role of nursing Informatics :

Nusing Informatics means using a computer system to recards health care activities of the clients.

* these will used to store the clients information indetailly.

* maintain privacy and confidentiality of clients reports.

* protect the clients information from thefts.

* it will be useful like a communication system inbetween nurses and other health departments.

* in these case the daily assessment is very essential so it is very beneficial.

This is the role of nursing Informatics here.