Patient Data (Essay Sample)
Hello I need this by 10pm on Wednesday 9/2/15.
To ensure the sharing of patient data is pertinent to the patient and useful to nurses and members of the health care team, there should be an organized, logical order in the way the information is documented.
Read the patient information below and arrange the information into subjective and objective data. Include this in your discussion post along with answers to the questions that follow.
Alert and oriented, restless, seems uncomfortable, short of breath on exertion, # 22 angio, saline well in left wrist, flushed with 3 mL of NS once, BP 180/96, RR 26 and shallow, temperature 98° F (36.7°C), AP HR 96 irregularly irregular; reports pain of 7 using a 0-10 verbal pain scale in lower extremities, patient states “I need my pain medication now, the pain is getting out of control”, 2 gm Sodium diet, 100 mL fluid with meds, patient consumed all of breakfast and fluids on his tray, allergic to Lipitor, transfer with one assist and walker x1, anti-embolism stockings when OOB, patient refused to get OOB (said “I just don’t feel like it now”), oxygen saturation 91% on 3 liters via N/C, breath sounds diminished bilaterally, cannot lie flat without becoming SOB, weight elevated 8 lbs today, severe edema in his legs to his knees, report oxygen saturation below 90% to the physician, skin on bilateral lower extremities is intact, dry, edematous, shiny, cool to touch with intact sensation bilaterally, medications: furosemide 80 mg, potassium chloride 40mEq daily, amlodipine 10 mg, pravastatin 40 mg, metoprolol 50 mg, lisinopril 40 mg all taken at 0900 by mouth without problem.
Use the scenario information above to address the discussion points by taking the information that was read in the assignments and applying it to the scenario.
Compare and contrast the advantages and disadvantages of SOAP method of documentation.
Discuss why it is necessary for all members of the health care team to use the same method to document a patient’s health status.
Using nursing judgment develop a diagnosis statement for the patient above which includes one NANDA-I diagnosis, an etiology and the defining characteristics (nursing diagnosis + related to + as evidenced by).
Identify the data cluster (grouping of significant data that points to the existence of the patient health problem) used to select the nursing diagnosis.
Identify one patient outcome (realistic, measureable and contains a time frame).
List at least four (4) interventions the RN would implement. Label each intervention as independent nursing action (intervention) or interdependent nursing action (intervention).
Provide a rationale for each action (intervention)
Provide a reference for each of your rationales
The documentation systems used in healthcare today reflect particular needs and preferences of the various health care agencies. SOAP notes are a highly structured and logical format for narrative charting used for documenting a patient's progress during treatment. Soap is an acronym for; Subjective, Objective, Assessment and Plan (Chiffi & Zanotti, 2015). The advantages of using SOAP notes in contrast to the disadvantages can be summarized in a table as follows;
Advantage of SOAP notes
Disadvantages of SOAP notes
-All the caregivers are adequately allocated by the location of the problem at the front of the chart.
-level of ability and consistency of formats might vary
-Care is problem focused
-The problem focus may reduce the patient's problems being solved
- Retrieval of information is easy
-Maintaining a neat up to date problem list is time consuming
-SOAP is constant in the nursing process
Sources: (Chiffi & Zanotti, 2015).
Why it is necessary to use the same method of documentation
Using same method to document a patient's health status is necessary for all members of the health care team because of a number of reasons. First, it helps to bridge differences in the documentation and communication methods which gets all team members in the "same movie.;
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