DARP charting assignment for lab assessment PDF

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Summary

2.06/2.25. Incorrect date format, too much preparation in the Action phase....

Description

Name: Allison Chinook Hosp. #: 61497- 3042 Sex: Female DOB: 1960, December 11

Data(D) subjective & objective data relating to stated focus Action(A)actions/interventions Response(R)patient response to actions/interventions Plan(P) future actions/future interventions

Student: Cassidy Johnson

ID 394341 Discipli Ti ne me 2021/JU 0730 Nursing L /6

Date

Focus

PATIENT CARE PROGRESS RECORD Data / Action / Res ponse / Plan

IVPM Medication Administratio n

D: Order for Allison called for administration of ranitidine, 50 mg at 0700 via IVPB. Assessments of IV site noted no redness, no swelling, no pain present. Primary line running 0.9% sodium chloride at 30 mL/hour as ordered, the hose not kinked or leaking. The label on the primary tubing was dated for earlier this day upon admission. No known allergies according to chart. ------------------A: Diluted 2 mL of 25 mg/mL of ranitidine in 0.9% sodium chloride 50 mL mini bag, as per the monograph and medication label. Administered to Allison at 0700, set in pump to be infused over 20 minutes according to orders and as signed on the MAR. Taught Allison about potential side effects of ranitidine, including nausea, increased heart rate and stomach upset. She was also informed about the signs of infection at the IV site, things that were previously assessed for: inflammation, pain, swelling, redness. Also, to watch for the IV bag, and the pump, it shouldn’t be beeping. -----------------------------------------------------------------R: Allison understood the teachings, restating them back to me. No initial reaction to medication, and IV was infusing steadily according to pump before I left. Allison was given her call bell, and stated she needed nothing else before my departure. ------------P: Vitals are to be assessed every four hours, and another nurse will be in at 0800 for another medication. Allison should be assessed after the 20 minutes have passed, to remove the secondary mini bag and replace the primary IV bag if necessary. ---------------------------------------------------------------------------C. Johnson, PNL...