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M6.6 DocuCare – Xavier Malton

 

Directions

 

In this Electronic Health Record (EHR), review the data to learn about the patient and his pain associated with ulcerative colitis.  Pay particular attention to the last nurses’ note when mother pulled the emergency call light and the MAR. Document the pain assessment data and nursing interventions under Pain Scale tab of EHR and provided as much data as possible. Use the narrative notes as needed to provide data available to you, when you might not have all data to use an assessment box easily.  Use the last narrative box for the nursing interventions carried out by RN Lovett.

 

*Be sure to document all possible data points per EHR accurately.

 

*Be sure to documents all possible nursing interventions performed accurately.

 

Here is the information from the Electronic Health Record (EHR) for you to document the pain assessment data and nursing interventions

 

Primary Admitting Diagnosis: Ulcerative Colitis 

Notes: Diagnosed with ulcerative colitis. Follow up with gastrointestinal physician as consulted. Complains of abdominal pain. Decreased appetite and multiple loose stools everyday for the past three days.

Family History: Patient’s grandmother diagnosed with ulcerative colitis at age thirty.

 

Pain Scale:

Pain Location – Abdomen

Frequency- Intermittent 

Type of Pain – Chronic 

Pain Goal – 0 No Pain 

Aggravating Factors – Movement, Coughing

Alleviating Factors – Rest, Medication, Immobility

Pain Scale Used – Wong Baker FACES 

Pain Characteristics – Aching 

 

Previous Nursing Notes 

 

1. Admitted to bed 6 in emergency room. Complaints of pain, see flowsheet. MD wishes to admit. Orders provided, will follow.

 

2. Admitted and transferred to pediatric unit per MD orders. Gastroenterology admitting. Vital signs stable. Transported via stretcher with parent to unit. Care released to Lovett, RN.

 

3. Admitted to unit per emergency room. Report received from Ross, RN. See flowsheet for details. Parent at bedside. no concerns at present time.

 

4. Mother pulled emergency call light. Xavier in bathroom doubled over in pain and can’t get off the toilet. Screaming “Something hurts really bad!.” Assisted Xavier back to bed, call light in reach, bed in low position, mother at bedside. Provider notified.

 

Vital Signs (Last three sets taken)

 

Blood Pressure – 102/58,  Heart Rate – 88, Respiratory Rate – 20, Oxygen Saturation – 100 on room air, temperature 98 oral

Blood pressure – 98/56, Heart Rate – 90, Respiratory Rate- 18, Oxygen Saturation- 100 on room air, temperature 98.2 oral

Blood Pressure – 106/60, Heart Rate – 88, Respiratory Rate- 22, Oxygen Saturation- 100 on room air, temperature 98.2 oral

 

Intake/Output

Intake – 60mL (ice chips)

Output- 200mL ( two stools and 200mL urine)

Balance= -140mL

 

MAR

codeine phosphate-acetaminophen 5 milliliters by mouth as needed

(Protocol/Note 12 mg codeine and 120 mg acetaminophen/5 mL As needed for pain)

 

Orders

Regular Diet

Frequent Vital Signs 

Frequent Intake and Output Assessment 

 

Plan of Care

Nursing Diagnosis – Chronic Pain Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe, constant or recurring without an anticipated or predictable end, and with a duration of greater than 3 months

 

Diagnosis Type – Actual 

 

Diagnosis Criteria- Physiological 

 

Expected Outcomes

The patient will demonstrate signs of decreased pain (relaxed facial expression and posture).

The patient will verbalize relief or control of pain.

The patient will state an understanding of the prescribed medication regimen.

 

Nursing Interventions Independent

Assess the patient’s ability to complete routine activities of self-care.

Encourage verbalization of feelings concerning pain issues; provide support.

Explore factors that relieve, worsen, or precipitate pain.

Instruct the patient to notify the caregiver of all episodes of pain.

Observe for nonverbal cues of discomfort.

Perform pain assessment every four hours. 

 

Nursing Interventions Collaborative

Administer medications as prescribed, and monitor for effect

Explore alternative therapies with the patient that may be beneficial, such as acupuncture, herbal therapy, and biofeedback.

Treat the underlying disorder as prescribed, and monitor for response.
 

Again please be sure to document all possible data points per EHR accurately. Be sure to documents all possible nursing interventions performed accurately.

 

Thank you.

SCIENCE
HEALTH SCIENCE
NURSING
NUR 109