Charting Assignment (20 pts) This assignment is related to the

Charting Assignment (20 pts) This assignment is related to the course outcomes: * Recognize basic concepts and principles of nursing practice in the health care environment. * Relate knowledge and science to nursing practice. Directions: Use the attached case study to complete the questions and tables provided on the attached pages. This activity is due September 29th by 2359 in the D2L assignment folder and is worth 20 points. Case Study Date: Use any date Shift: 0700-1530 You are assigned to care for Mr. J in room 100 bed 1. He is a 76-year-old patient who has been hospitalized with pneumonia. He has allergies to sulfa & tape. He has been a LTC resident x 8 yrs, and has no family. He has a history of smoking 2 packs of cigarettes per day for 30 years and still goes out frequently to smoke. His co morbidities include COPD, and HTN. He is 5’8″ tall and weighs 130 pounds. He has lost 20 pounds in the last year. He has orders for oxygen at 1 to 2 L/NC continuously to keep sats 90% or above; Albuterol 2.5mg in 3 mL normal saline nebulizer scheduled every 4 hours, and every 2 hours PRN for shortness of breath; Augmentin 500 mg PO every 8 hours. Acetaminophen 650 mg PO every 4 hours PRN pain not to exceed 3,000 mg in 24 hours. [The night shift reported that he had a restless night with several episodes of severe coughing which produced large amounts of thick greenish-yellow sputum. Temp was 102.0 degrees F (Temporal). at 0200. He was medicated at that time with Tylenol 650 mg orally. Temp was 100.2 degrees F (Temporal). at 0300. Given albuterol nebs at that time. Lung sounds were bilateral rhonchi which do not clear with coughing, and wheezing in upper lobes; wheezing improved after nebs. Oxygen sats ranging from 91 to 93% on O2 @ 1 L/NC. Intake 250 mL & Output 100 mL NOTE: DO NOT CHART WHAT HAPPENED ON NIGHT SHIFT] After report at 0700, you enter the room to evaluate his status. He is lying flat in bed, coughing and trying to catch his breath. The results of your assessment: V.S.: T 99.8 (Temporal), AP.88 + reg, RR.26 + labored, BP: 150/88 RUE, lying flat, Pulse ox sats 92% on O2 @ 1 L/NC. You note he has a barrel shaped chest and clubbing of the fingers. He states, “I was up most of the night with this cough. My ribs hurt from all this coughing too.” you notice that his face is pale, his skin is clammy, and he complains of feeling “terrible”. Lung sounds: Bilateral rhonchi heard throughout lung fields, along with faint wheezing in the upper lobes. Productive cough with thick greenish-yellow sputum. Skin pale, warm to touch, capillary refill time 3 sec. in hands and feet. No edema noted. Pedal pulses present in both feet. During the assessment, he removed his oxygen cannula to walk to the bathroom. He experienced increased shortness of breath while walking, and O2 sats immediately upon returning to bed were 88% on room air. RR increased to 30 + labored. Circumoral cyanosis also noted after returning from the bathroom. At this time he states he wants to go outside to smoke. He also asks for a cup of coffee and tells you he doesn’t want any breakfast. Part One: Subjective and Objective Data Collection (10 pts) Column I: Identify the 2 most important health needs or problems based on your 0700 assessment. Provide the rationale (reason) why you chose the first problem as the most important. Column II: Identify the subjective and objective data from your 0700 assessment related to each problem (separately) Column III: List factors related to the problem (hint: look at the patient history and night shift report) Most Important Health need or problem II. Identify Your Assessment Subjective and Objective Data related to problem #1 Factors contributing to problem #1 Problem #1 (most important): Why is this problem the most important: Subjective: Objective: I. Second important need or problem II. Identify Your Assessment Subjective and Objective Data related to Problem #2 Factors contributing to the problem #2 Problem #2: Why is this problem less important than problem 1 above: Subjective: Objective: Part Two: Action (6 pts) What actions/interventions will you do at this time, based on your two identified problems and 0700 assessment findings and patient status at that time? Be sure to also look at the patient’s orders in the scenario above. Problem #1 actions: Problem #2 actions: Part Three: DAR Nursing Note (4 pts) Choose the most important (priority) health need or problem you previously identified from above and write a nursing note using proper DAR format. Use your 0700 assessment data information and your identified actions for that problem. Make up the patient’s response to your actions (that is, make up what happened as a result of your nursing interventions). Part One Correct Partially Correct/missing some information Incorrect or missing Identified 2 problems with rationale; correctly prioritized number one problem 2 pts 1 pt 0 pts Identified subjective and objective data for problem one 4 pts 1 to 3 pts 0 pts Identified subjective and objective data for problem two 4 pts 1 to 3 pts 0 pts Part Two Correct Partially Correct/missing some information Incorrect or missing Identified appropriate actions for problem one 3 pts 1 to 2 pts 0 pts Identified appropriate actions for problem two 3 pts 1 to 2 pts 0 pts Part Two Correct Partially Correct/missing some information Incorrect or missing Create DAR note for problems one, including all of the elements and correct format. 4 pts 1 to 3 pts 0 pts Total score _________/20

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