Question

Documentation Exercise A Scenario: Your patient is Beth Freeland, hospital ID #792283, and she is in Room 312. Her BD is 6-4-70 and admission date was 8-8-13. Today's date is 8-10-13. It is 1030 and you just completed patient teaching. You verbally presented information regarding Ms. Freeland's specific dietary needs, which is to increase her potassium (K+) and magnesium (Mg+) intake. You told her about a variety of foods that provide K+ and Mg+,including fruits, vegetable, and meats. You knew it would be difficult to remember from memory all the food sources for both nutrients, so you pro- vided her with a written list of foods. She asked several appropriate questions, which you answered. Then she told you, "1I will ty to really increase how many vegetables and fruits that I eat. I just got out of the habit and have been eating mostly fast foods, burgers and stuff." The foods on the written list that you talked about induded OJ, molasses, tomatoes, apricots, trout, cod, tuna, pork, peaches, and prunes for K+ and various nuts, oatmeal, avocado, halibut, peanut butter, and rice for Mg+. 50. On a nurse's note form (Figure 23-1) document this patient teaching session and include evaluation of your effectiveness.

Answer 1

Date - 8/10/13

Nurses note :

Patient is conscious and oritened to time ,place and person . Her vitals are within normal limits . Morning medications are given as per prescription . On assessing her blood reports it was found that potassium and magnesium are less than normal limits . So ,I gave her health education regarding dietary methods to increase her potassium and magnesium . As it would be difficult for her to remember all that I have her a written list of foods to be taken after having consultation with the dietician which included - tomatoes , molasses ,apricots ,trout ,cod ,tuna ,pork ,peaches , prunes for potassium and various nuts ,oatmeal ,avocado, peanut butter rice and halibut for magnesium . Also gave her health teaching about the adverse affects of eating fast foods . I encouraged her to eat more leafy vegetables and fruits rather than eating burgers and pizza's .

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