Christopher Parrish DA PDF

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Christopher Parrish Documentation Assignments 1. Document your focused gastrointestinal and dietary assessment of Christopher Parrish.  Vital signs  Assess bowel sounds o Ask “When was your last bowel movement?” o Ask “How does your stool look like?”  Asses patient eating habits o Ask “Are you getting an adequate dietary intake?”  Assess placement of NG tube o Aspirate NG tube o Flush NG tube  Insure patient gets diet prescribed by PCP o High-fat, high-calorie, high-protein regular diet with high-protein snacks  Insure patient takes Pancrelipase and Multivitamins o Pancrelipase enzymes five capsules PO with meals and tube feedings; Three capsules PO with snacks and multivitamin 2 tablets PO every morning  Insure patient gets the NG tube feeding when ordered o Fluid nutrition (1.5 kcal/mL) in NG tube; 720 kcal in 8 hours during the night  Change patients position to a sitting position when eating meals, snacks or placed NG tube for feeding  Educate patient on NG tube feeding, positioning, and risk for aspirating 2. Document two nursing diagnoses for this patient.  Imbalanced nutrition R/T inadequate dietary intake AEB weight loss of 6 kg (13.2 lb) and weakness  Risk for ineffective airway clearance R/T buildup of mucus in lungs AEB respiratory condition 3. Document your priorities for care of this patient.  Vital signs o Maintain SpO2 above 94%  Assess GI for bowel movement  Assess dietary intake o Patient should have a high-fat, high-calorie, high-protein regular diet with high-protein snacks From vSim for Nursing | Fundamentals. © Wolters Kluwer

Administer prescribed Pancrelipase and Multivitamins o Pancrelipase enzymes five capsules PO with meals and tube feedings; Three capsules PO with snacks and multivitamin 2 tablets PO every morning  Adminiter prescribed NG tube feeding o Check placement of NG tube o Aspirate NG tube o Flush NG tube o Risk for aspiration should be prevented by positioning patient in a sitting position o Fluid nutrition (1.5 kcal/mL) in NG tube; 720 kcal in 8 hours during the night  Educate patient on diet, BMI, intake/output, risk for aspiration, positioning and NG tube feedings 4. Describe the age-related considerations you will use when caring for Christopher Parrish.  Ensure patient is informed about diagnosis and care o Answer any questions or concerns the patient may have  Maintain privacy  Nutrition o Ensure patient knows that a balanced food intake, exercise, and rest is important  Safety o Discuss any substance abuse o Inform about driving safety, gun safety, and sports safety  Promoting Health and Preventing Illness o Inform patient about regular physical, vision and dental examinations o Engage in safe-sex practices if sexually active o Inform about dangers of STIs 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.  Safety Measures o Wash hands o Introduced self o Identified patient o Ask “Do you have any allergies?”  Patient replied, “No, I am not allergic to anything” o Put on gloves 

From vSim for Nursing | Fundamentals. © Wolters Kluwer

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Communications Past History o Ask “Do you have any medical problems?”  Patient replied, “Yes, I have Cystic Fibrosis” o Ask “Are you a smoker? If so, how many packs a day?”  Patient replied, “No, I do not smoke” o Ask “Do you take any medications?”  Patient replied, “Yes, I take enzymes for digestion” Current Ilness o Ask “How are you feeling?”  Patient replied, “I am tired” o Ask “What happened?”  Patient replied, “I haven’t been eating much lately” o Ask “Whend did the symptoms start?”  Patient replied “I haven’t been eating well for more than a week or so” o Ask “How many bowel movements do you have everyday and what is the consistency?”  Patient replied, “I usally have one or two, they’re mostly formed but soft” Assessment o Vital signs  T: 99F, RR T- 99F, HR-83 bpm, RR-12, BP- 120/72, SpO296% o Ask “Do you have any pain?”  Patient replied, “No, I do not have any pain” o Head-to-Toe  Head: AAOx3  Chest: Normal heart and clear lung sounds  Abdomen: Flat, non-tender, normoactive bowel sounds  Arms: Normal findings  Legs: Normal findings  Skin: Normal skin color and turgor  Mucosa: No signs of dehydration o Interventions  Sitting position  Checked placement of NG tube  Aspirated gastric content  Flushed NG tube  Began fluid nutrition From vSim for Nursing | Fundamentals. © Wolters Kluwer

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o 5 tablets Pancrelipase PO  Order to MAR, label to MAR, medication to patient  6 rights were followed o Fluid nutrition  Order to MAR, label to MAR, feeding to patient  480 mL at 60 mL/hr Education o BMI  Patient, “What can I do to gain weight and keep my BMI up?” RN, “Continue high-calorie diet and NG tube feedings to help you gain weight faster” o Diagnostics  Patient, “I want to learn what all of these numbers mean in my labs”  RN, “ Well, your albumin and vitamin D is low probably because you have not been eating well. It is important for you to eat well and take your vitamin supplements” o Diet  RN, “It is important not to skip meals and follow high-fat and high-calorie diet. Remember to take your enzymes before you eat” o Intake/Output  RN, “ We are recording your fluid intake and urine output. It is important to let us know when you drink fluid and urinate” o Positioning  RN, “If you are not able to position yourself in bed, I can help with that”  Patient, “I can position myself without a problem” o Risk of aspiration  Patient, “Am I at risk for that?”  RN, “ We want to make sure you don’t aspirate or bring up any of the feeding and

From vSim for Nursing | Fundamentals. © Wolters Kluwer

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keeping the head of your bed up can help with minimizing the risk” o NG feeding  RN, “Your stomach might get pretty full which may cause nausea or pain. Let us know of that happens, we can always adjust the feeding or turn it off to give your stomach a break” Patient handoff

From vSim for Nursing | Fundamentals. © Wolters Kluwer...