Download Nursing Documentation Revisions Unit

Nursing Documentation Revisions
Unit-Based Practice Scenario
VUH 8th Floor Inpatient Medicine
KEY
Name: ____________________
Unit: ______________
Date: ___________________
Directions for Completing Practice Scenario
You have completed the LMS Nursing documentation modules and here is your chance to practice. Please use the content
provided in the following scenario to practice nursing documentation to become more familiar with the layout and flow. In
this scenario, the Nursing Admission History has already been completed and you will begin with an Admission Assessment.
Open HED Train, choose any training patient with last name of ZTRAINHEDUP on your unit to complete documentation.
Practice Scenario: for patient with Age: _26__ & Diagnosis(es): __Cystic Fibrosis_exacerbation____________
Background: 26 year old white male w/ past medical history of Cystic Fibrosis who presents w/ 1 week of worsening SOB, productive cough
anorexia, and pleuritic chest pain concerning for subacute CF exacerbation and pneumonia. Patient has been c/o severe pain for several days.
Treating with tobra, zosyn and linezolid.
PAST MEDICAL HISTORY: Cystic fibrosis; Exocrine pancreatic insufficiency; Chronic pain; Depression
The CP has already documented Vital Signs: T98.0, RR 28, HR 83, Sp02 96% on 3L/min NC, BP 109/64, weight 50Kg, height 173 cm, BMI
16.8
1. Admission Baseline Assessment Data:
Pain: rates rib pain as sharp and with each inspiration (must annotate ribs, choose sharp & inspiratory from drop down) 7/10
on numeric scale. Pain goal of 3. 1 mg Dilaudid IV given 1 hr ago in ED but continues to have pain so you called Dr Patel. He
ordered 1 mg Dilaudid IV stat and said he would be up to see pt. (document a communication event note)
Neuro: AA&O x4. WNL
Cardiac/Tissue Perfusion: RRR; No murmur, rub, S3, S4; Cap refill <3s; Pulses +2, x4 extremities. WNL
Respiratory: Diminished breath sounds throughout; Course crackles bilateral bases; tachypnea, shallow breaths due to pain
and SOB on exertion. Cough productive yellow sputum; Dyspnea on exertion. Problem Gas Exchange Alteration, document in
dropdowns
GI: Soft; Normoactive BS x4 quads; last BM 2 hrs ago; no N/V. WNL
Skin:. Warm, dry; No cuts bruises or lesions. Be creative when filling out braden.
Renal/UR: Voiding without difficulty; Concentrated urine. OEL denote concentrated in drop dwon
Activity/Musculoskeletal: Ambulates without assist but becomes SOB with very minimal activities. Generalized weakness
noted but moves all extremities. Reports that his inability to do the things he wants to do because of the shortness of breath is
one of the main reasons he came to the hospital. Activity intolerance – select generalize weakness
Fluid/Nutrition: Appetite poor but that is pretty normal for him for the last few years. Reports that he is drinking plentyhate 2 boosts before coming to the hospital. Ate ½ CF diet for breakfast. Denies loss of weight recently. WEL-annotate poor
appetite for years
Falls Risk/Safety: No signs of abuse; Be creative with Morse- denote that pt is a moderate fall risk d/t medications. Falls Risk
Medications: Multiple medications but has been on for years and not experiencing any problems. WNL
Lines: PIV 20 g to R cephalic started in ED. Infusing d51/2ns @ 125mL/hr. start a new line and document that IV infusion
started.
ADLs: reports since been sick he needs help with bathing and dressing and gets to short of breath to cook his meals or walk
his dog. ADL deficit
Infection/ Metabolic Assessment: BG on admission was 215. Admitting dx of pneumonia. Glucose Alteration and Infection.
Nursing Documentation Revisions
Unit-Based Practice Scenario
Psychosocial: Patient is withdrawn; distracted by social media on his laptop. Depressed mood; flat affect. Family present and
planning to stay overnight. Patient is noncompliant with BG checks as ordered. Select a problem(s) and annotate
Saving: As you save your assessment, denote two (max of 3) Priority Problems by clicking the !! on the review screen
before saving and confirming.
2. Plan (Hint: PLAN tab)
Select a goal for each of the priority problems you selected. For example:
Pain: Goal 3/10 on numeric scale.
Respiratory: Self-report ability to breath better, Return to Baseline rate and depth of respiration
3. Education & Nursing Interventions: Document the following (Hint: Education & Interventions tab)
Care Contact: preferred language: English, learning mode: web-based, Care contact name: Betty White, role: Mother, phone #:
615-936-0332
Education Session: patient and Care contact 1, were given handouts,and verbalized understanding of VUMC general & unit specific
education and education re: meds for pain management.
Interventions
 Pain control care : medication & positioning
 Strict Intake & Output ( under fluid therapy care, strict I&O)
 T, CB &Incentive spirometer( respiratory interventions)
 Continuous Pulse ox monitoring ( respiratory monitoring)
 HOB elevated 30 degrees (Activity/Muscuskeletal, under positioning interventions drop downs)
 Blood Glucose before meal was 140 ( infection/ metabolic interventions)
4. Re-Assessment: You have just performed a focused re-assessment. Document the following.
Remember to show all to display the Re-assessment care category.
In your re-assessment these are the only changes you noted.
Pain: 4/10 numeric score & pt reports doesn’t hurt as much to breath
Cardiac/Tissue Perfusion: Tachycardia, HR 135.
Respiratory: Breath sounds inspiratory wheeze noted throughout; Dyspnea at rest.
5. End of Shift: It is now the end of your shift. Document the following:
You note that pain is better controlled w/ new pca orders but resp status has declined and pt is now dyspnic
at rest and o2 sats are in the low 90s. IV antibiotics & steroids started as well as Resp Treatment. Pulse
increased probably because of the steroids. BG is only sl elevated. Need to assure that the next shift gets a
vanc trough level at 1800 as well as closely monitors for further resp status decline as well as teach family
about pneumonia and importance of getting flu& pneumonia vaccines.

Response to Care/Recommendations (Hint: PLAN tab) Example below
Pain improved w/ pca, resp status decline w/ dyspnea at rest & o2 sat low 90s, Started Antibiotics, breathing txm&
steroids, BG improved &only sl elevated, HR up. Vanc Trough @1800, educate pt /family on pneumonia and impt of
vaccinations. Monitor for resp decline.
Question: Since there will be several weeks before all units have transitioned to the new tabs and documentation model, if
your unit has gone live but a patient transfer to you from a NON IMPLEMENTED unit, what will be the best way to view the
documentation from the sending unit?
(Remember, documentation will not be shared between the old and the new tabs)
Answer: ALL DOC
 Upon completion, please sign and return to CSL by 9/14/15 . 
Signature:
Date: