Need some quick help with charting.

[JasonKa]

10/15/2013

0900

DATA:

• PT admitted for persistent vomiting
  
• Stable vital signs
  
• Dry skin, turgor poor
  
• Urine output at 200cc of dark pungent smelling urine
  
• Complains of thirst
  

ACTION:

-performed morning care

- IV fluids administered at 1000 cc 0.9% NS q8h as per doctor's orders

-nothing given orally

Response:

- no vomiting during morning care

• urine output averages 60cc per hour throughout morning
  

Narrative:

Mrs. Jones admitted for persistent vomiting over past 4 days. VS are stable. Skin appears dry, turgor is poor. Urine output at 200cc of dark pungent smelling urine over past 8 hours. Complains of excessive thirst. As per doctor's order IV administered during morning care at 1000 CC 0.9% NS. Nothing is given orally. Patient does not vomit during care given and urine output averages 60cc per hour throughout morning.

(The original scenario was Ms. jones admitted for persistent vomiting over past 4 days. She is very weak, but vital signs are stable. Skin appears dry, but turgor is poor. Urine output at 200cc of dark, strong smelling urine over past 8 hours. Complains of excessive thirst.

Physician orders:

1) NPO

2) IV Fluids - 1000 cc 0.9% NS q8h

3. Report all vomiting

You as the nurse administer morning care and regulate IV correctly throughout morning. Ms. Jones does not vomit during time cared for. Urine output averages 60cc per hour throughout morning

Write a narrative and focus note)

[Kuriin, BSN, RN]

Wouldn't this patient be hypoglycemic from having severe emesis and NPO? Surprised there's no dextrose in the IV with that lactated ringer.

[nurseprnRN, BSN, RN]

What lactated ringer (sic)? NS is running. D5W gives you no more than 200 calories per liter and you can figure out how many grams of sugar there is in a liter because you took chemistry. Hint: It's not too darn much. No indication for IV dextrose at this point.

Normal people have glucagon reserves (where? do you remember?) to keep blood sugar acceptable during NPO periods. If not, we'd all be dead after 48 hours of that norovirus GI flu, and we aren't. You can fast for many days and not become hypoglycemic.

My question is, if she's thirsty, not vomiting, and still behind in her fluids, though u/o is adequate in amount though more and lighter would be better, why not ask for a dietary prescription from the physician to begin oral intake c clear sips, advance as tolerated? At least, where's the good oral care?

OP, I'm not sure I understand what you want to know. Is it that you want to know if your note meets criteria? What do you think? Let's see it! We aren't going to write it for you because we don't do your homework. Show us what you would write and begin the conversation.

[Kuriin, BSN, RN]

Thanks, grntea. :-)

[JasonKa]

Sorry folks I formatted this wrong. Our professor just gave us a small case study which is the paragraph in brackets at the bottom. The assignment is to write a progress note in the narrative and focus format. So we just have to write the paragraph she wrote, but in a narrative and focus note.

[Esme12, ASN, BSN, RN]

Write what you see......

Mrs. Jones admitted for persistent vomiting over past 4 days. VS are stable. Skin appears dry, turgor is poor. Urine output at 200cc of dark pungent smelling urine over past 8 hours. Complains of excessive thirst. As per doctor’s order IV administered during morning care at 1000 CC 0.9% NS. Nothing is given orally. Patient does not vomit during care given and urine output averages 60cc per hour throughout morning.

(The original scenario was Ms. jones admitted for persistent vomiting over past 4 days. She is very weak, but vital signs are stable. Skin appears dry, but turgor is poor. Urine output at 200cc of dark, strong smelling urine over past 8 hours. Complains of excessive thirst.

Physician orders:

1) NPO

2) IV Fluids - 1000 cc 0.9% NS q8h

3. Report all vomiting

You as the nurse administer morning care and regulate IV correctly throughout morning. Ms. Jones does not vomit during time cared for. Urine output averages 60cc per hour throughout morning

Now tell me how would you start your note......

Assisted patient with morning care....pt remains weak....skin is dry, turgor is poor.....

Now you tell me what is next