Question

Documentation Exercise Scenario: Question 78 refers to this scenario. Your patient is a 14-year-old female, Charlene Jefferson, who has chronic renal failure from an inherited disorder. She has been started on dialysis and has a dialysis shunt in her left forearm. She is refusing to eat and will not speak to her doctors. Her doctors told her she will have to get a feeding tube if she does not eat. Based on your understanding of developmental issues, you believe Charlene is sad and angry about her diagnosis and probably does not like that she looks different because of the shunt in her arm. You realize that addressing all the issues will take several conversations, but your goal now is to establish a rapport with Charlene. You have just a few minutes and you enter her room. You introduce yourself and give her a big smile. You pull up a chair and sit with her so that you are at eye level with her. You have a relaxed posture but focus your attention on her by making eye contact. "Hi, Charlene, my name is Cathy. I'm your nurse today. How are you doing?" Charlene quietly says, "Okay," and stares out the window. "I sense you're not happy, Charlene, what happened?" you ask. Charlene tells you a little bit about her health issues and ends by saying "I hate having this problem. I feel like a freak!" "Do you feel different from your friends?" you ask. When she nods her head yes, you say, "I really want to help you, Charlene. Can we set up a time to talk later today?" Charlene nods yes, and you determine that you can come back at 11 a.m. to talk with her. You come back at 11 a.m. on the dot, sit down, and smile at her. You change your facial expression to one of concern, and say, "Let's pick up where we left off, Charlene. Tell me about your friends and how you feel different." Charlene begins to open up a bit about her life, expressing some general anger at her situation and her fears that she will get sicker. You are aware that Charlene needs information and hope. You provide her with written handouts on renal failure and hemodialysis. She asks you about a kidney transplant. You explain a bit about how a transplant works and offer to have a member of the transplant team drop by and visit with her. Charlene says she is very interested in hearing more, so you tell her that you will arrange it. 78. Use the nurse's note (Fig. 6.1) at the end of the chapter to document your interaction with Charlene.

Answer 1

78.14 yr/F admitted with history of chronic renal failure genetic in origin and on dialysis. She has shunt on her left forearm.

Cheif complaint :Refusing to eat and provider has ordered for a feeding tube .

Upon examination she is anger and refusing to engage in conversation.

A therapeutic communication is established and identified as in developmental stage of identity vs confusion .Fidelity established and patient opened up conversation by expressing feeling sad.Hope instilled and offered for renal transplant team.