sweetpea808

We just got thrown this patient teaching assignment that's due monday, with very little instruction and I'm having a hard time coming up with good answers. Please let me know what you can make of it/point me in the right direction. As you can tell it takes a bit of creativity. Thanks a lot.. :wink2: Client Profile: 42 yrs old Divorced 12 yr old daughter in gr. 6. School 2 blocks from home Chartered accountant - several small business clients, works out of home Admitted to a medical unit w/ complaints of intermittent bouts of abdominal pain, diarrhea , and rectal bleeding. Has had severe diarrhea and weight loss (8 kg over 2 months) Very pale, tires easily, dehydrated Dr believes she has Ulcerative Colitis affecting her sigmoid and descending colon. Dr believes it can be controlled w/ medication. Surgery is not required at this time. Pt booked for a colonoscopy tomorrow to confirm diagnosis 1-2 days after colonoscopy is to be discharged w/ following meds: Sulfasalazine, mesalamine, and prednisone Right now she: Has an IV of D5NS w KCL meq Is NPO To complete the Peg Prep routine for the colonoscopy Describe what you know/would like to know about the pt that would facilitate your planning Describe how you would assess the pt's learning needs (what they already know, need to know - demonstrate that you have researched the pt's diagnosis, tests and treatment) What are the pt's learning needs? Identify ALL of them Identify 3 priority learning needs and write a nursing diagnosis for each one (3)

What is the "trick" you keep talking about? ha ha

Okay, This is what I've done.. tell me what you think. I left out the bowel stuff since he's continent and we chart only things that are out of the ordinary.. I don't really think it needs to be on there. Focus: Urinary retention Data: Pt feels they are not emptying bladder despite the need to void more frequently. Urinary output significantly declined in last 24 hrs. Last void 16 hrs ago. Action: Palpated bladder, distension noted and pt unable to pass urine. Foley inserted as ordered by Dr. smiley to relieve urinary retention. 12Fr 10 mL balloon to gravity. Response: Pt indicated no pain during insertion. Draining clear yellow urine. 1000 mL out Focus: Frontal headache Data: Pt is requesting pain medication for relief of a frontal headache that started approx 1 hour ago. Pt c/o being uncomfortable and anxious. Pain is rated at 6/10 on pain scale. VS: BP168/92 P88 R20 T36C Action: Notified Dr who advised Pt be given Tylenol ES tab i. Writer administered Tylenol ES tab i as directed to pt. Response: Reassessed pain. Now 1/10. Pt states "I feel so much better".

I have an assignment where I have been given a scenario and I need to complete progress notes for it. The charting is in Focus/DAR format... data/action/response. I struggle because is so hard to think of a focus to start the documentation and to split it in DAR. Can anyone give me some hints or show me how this is done? Here is the project I was given: "In the last 24 hrs urinary output has been diminishing. Pt has indicated that he feels as though he is not emptying his bladder despite needing to void more frequently. This AM his bladder was distended and he is unable to pass his urine. He is quite uncomfortable and anxious, and is requesting Tylenol ES tab i for relief of a frontal headache. He is continent and successfully emptied his bowels yesterday. His physician has just ordered a #12-10cc foley catheter to continuous drainage to be inserted immediately to relieve urinary retention. VS: 168/92-88-20 Temp -36C "