Review Narrative Note for Case Study?

[nursechilespice, LPN]

Jamie Lynn was admitted to your acute medical unit at 0600 hrs today for investigation of query appendicitis”. You are assigned to care for her on the day shift. The radiological department was very busy last night and the portable x-ray machines were broken and being serviced. Jamie Lynn is still waiting for her abdominal x-ray and other radiographic tests.

At the start of your shift 0730 the call bell is constantly ringing from Jamie's room. When you enter the room Jamie is very upset and her mom is with her. Her mom is very angry that the x-rays have not been completed. Jamie is pale, sweating, and very anxious. She is moving about constantly in her bed and her intravenous line is wrapped around her arm many times. The dressing that maintains the intravenous is damp. You do a quick physical assessment and note the following:

•Vitals: T 38.9 P124 R26BP: 145/70 Sp02: 97% on room air.

•Pain: 8/10 on a scale of 1 to 10. Region: right lower quadrant of abdomen.

•Client guards abdomen on palpation. Cries and screams don't touch me” during palpation.

At 0745 you notify the charge RN of the situation and prepare your information and call the MRP Dr. Williams to inform him of Jamie's present condition. The doctor orders pain control, states he will see the patient before 1000 hrs, and orders the IV solution to be changed to D5W to run at 100 cc/hr. You also plan to call the radiology department and discuss the situation with the radiologist on call, Dr. Amouz-Kant and arrange for her diagnostic tests to be completed as soon as possible. After these phone calls, you discuss the issue with Jamie and her mom and give them an update of your plan for this morning. At 0800 you ensure that Jamie's intravenous catheter is in situ and change the dressing to secure it. You change the IV to run the new solution. At 0815 you have the RN on your team administer 2 mg of morphine sulphate and 25 mg of gravol via the intravenous.

Here is my narrative note...

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26/10/2015

0730 patient is alert and awake with mother present. Patient is pale, sweating, anxious and constantly moves about in bed. IV line wrapped around patient's arm- dressing that maintains IV is damp. T 38.9; P 124; R 26; BP 145/70; Sp02:97% on room air. Pain of RLQ region of abdomen is 8/10 on scale of 1/10. Patient states don't touch me” during palpation and guards abdomen on palpation. Paulina Petit RPN

0745 notified charge RN of situation and called MRP Dr. Williams to report patient's current condition. MRP TO pain control, IV solution to be changed to D5W to run at 100 cc/hr and states he will see patient before 1000. Then phoned oncall radiologist Dr. Amouz-Kant and discussed situation to arrange patient's diagnostics to be completed asap. Updated patient and mother of care plan and discussed the issue with patient and mother. Paulina Petit RPN

0800 patients IV catheter is in situ and changed dressing of IV. IV solution changed to D5W run at 100cc/hr as per MRP TO. Paulina Petit RPN

... Sorry for the LONG text, I'll dismiss my DAR, (Objective/Subjective, Action, Response) I know that DAR's are more patient centered and focus primarily on patient's concerns and how to solve them... If anyone could please read over my Note and critic it I would greatly appreciate it!

-Paulina

[meanmaryjean, DNP, RN]

"Pale and sweating" is diaphoretic, "Moving about constantly in bed" is restless. If you are noting IV dressing being damp, you should include in that same statement that you checked for patency. If NOT patent, document that site D/C and the condition of the catheter when removed (is it intact?). You can leave out 'on a scale of 1/10' as saying the patient rates pain as 8/10 includes the scale as the denominator. Include PATIENT rates pain, as from your note it almost looks like YOU assigned the number, KWIM?

[hnstudent]

How did you do that R in DAR?