Documentation- Nursing
Documentation Practice
Case Study
John D. is a 20 year-old male college student with a past medical history of asthma who was admitted to the hospital this evening.
He has a 20-hour history of nausea and vomiting after eating at local fast food restaurant.
He was seen this morning in the college health clinic and sent to his dorm room with orders to drink Gatorade.
This afternoon, his experienced dizziness and fainted, his girlfriend called 911.
His primary complaint is “thirst, abdominal pain and gurgling”. He also states he has “only peed once today”.
He was seen in the ER and an IV was started, he received 1 liter of IV fluid (0.9% sodium chloride) over 1 hour and is currently receiving 125 ml/hr of IV fluid through a left antecubital fossa IV site.
Upon exam, it is noted that:
His vital signs are: BP 90/54, P = 120, RR = 20, T = 100.8F.
His mucosa is noted to be dry. His skin is warm and dry with poor turgor.
His bowel sounds are hyperactive. He vomited 50 ml of green gastric contents.
He is able to urinate 20ml of dark amber urine for a urinalysis.
His lungs were reported to be clear in the ER, he now has wheezes in all lobes.
He is alert and oriented x3 and is moving all extremities strongly.
His IV site has no signs or symptoms of infiltration (no redness, pain of swelling at the site).
Patient requests parents be notified of admission and that they be asked to bring his extra inhaler from home as he had lost his several days ago.
Documentation Practice
Narrative Charting
PROGRESS NOTES:
Date/Time
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Case Study
John D. is a 20 year-old male college student with a past medical history of asthma who was admitted to the hospital this evening.
He has a 20-hour history of nausea and vomiting after eating at local fast food restaurant.
He was seen this morning in the college health clinic and sent to his dorm room with orders to drink Gatorade.
This afternoon, his experienced dizziness and fainted, his girlfriend called 911.
His primary complaint is “thirst, abdominal pain and gurgling”. He also states he has “only peed once today”.
He was seen in the ER and an IV was started, he received 1 liter of IV fluid (0.9% sodium chloride) over 1 hour and is currently receiving 125 ml/hr of IV fluid through a left antecubital fossa IV site.
Upon exam, it is noted that:
His vital signs are: BP 90/54, P = 120, RR = 20, T = 100.8F.
His mucosa is noted to be dry. His skin is warm and dry with poor turgor.
His bowel sounds are hyperactive. He vomited 50 ml of green gastric contents.
He is able to urinate 20ml of dark amber urine for a urinalysis.
His lungs were reported to be clear in the ER, he now has wheezes in all lobes.
He is alert and oriented x3 and is moving all extremities strongly.
His IV site has no signs or symptoms of infiltration (no redness, pain of swelling at the site).
Patient requests parents be notified of admission and that they be asked to bring his extra inhaler from home as he had lost his several days ago.
Documentation Practice
Narrative Charting
PROGRESS NOTES:
Date/Time
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| | |
| | |
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