Consfusing Documentation exercise!

  1. I am supposed to do a days worth of narrative nursing documentation on a made up patient.I am required to document at least once every two hours from the information listed below. Approved abbreviations are acceptable.

    How in the world would you document this???

    A 36 y/o primigravida who is 34 wks pregnant is admitted to the hospital with worsening preeclampsia. She is placed on complete bedrest. The OB wants her observed closely for signs of severe preeclampsia, which include hypertension, proteinuria, oliguria, cerebral or visual disturbances, pulmonary edema, epigastric pain, and sudden onset of severe edema. The patiend is also observed for an eclamptic seizure. The OB orders ests to assess fetal status...1)Fetal kick count daily 2)Nonstress test on admission 3)external fetal heart monitoring x40 minutes daily 4)ultrasounds daily x7days 5)biophysical profile on admission 6)amniocentesis for L/S ratio this P.M.
    High protein and 2Gm sodium diet
    Apresoline 50 mg IV on admission and Q6h PRN for P/P greater than 180/100
    The nurse assures this patient that everything will be done to make her comfortable and ensure the well being of her and her baby.
    The nurse encourages the patient to lie in the left lateral recumbent position at all times.
    The patients blood pressure is assessed Q1hX6 starting on admission at 1200 and q1h X4 then q4h if no increase.
    Intake and output is q4h with urine checked for proteinuria q8h
    Deep tendon reflexes and clonus assessed q4h
    Daily weight at 0630 in same amt clothing each morning. 2+pitting edema in feet and ankles as well as sacrum
    Mag Sulfate 4 Gms in 200ml D5W to run wide open to gravity on admission with Mag Sulfate 40Gms in 1000ms D5W to follow on the infusion pump at 2Gms per hour.
    Mag Sulfate level q4h;Follow protocol for level greater than 8mg/dl;with result of 4mg/dl
    B/P on admission 190/90, At 1500 B/P is 180/86. At 1600 B/P is 178/88. At 1700 B/P is 190/96. No observable signs of eclamptic seizure is observed (as written in MD's orders.)
    Last edit by riann458 on Nov 6, '07
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  2. 1 Comments

  3. by   Daytonite
    you will find information as well as examples and links to examples of narrative charting on this sticky thread:

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