Christopher Parrish
Documentation Assignments
1. Document your focused gastrointestinal and dietary assessment of Christopher
Parrish.
o Obtain vital signs
o Assess bowel sounds and when last bowel movement occurr
...
Christopher Parrish
Documentation Assignments
1. Document your focused gastrointestinal and dietary assessment of Christopher
Parrish.
o Obtain vital signs
o Assess bowel sounds and when last bowel movement occurred
o Assess placement of NG tube—due so before aspirating and flushing
o Assess for special diet implemented by doctor (check patient’
understanding)
▪ high calorie, high fat diet
o Assess patient’s eating habits
▪ Are they getting the meals they need on a daily basis?
o Assess use of vitamins or food supplements
o Ensure patient positioning is semi-fowler’s or higher
o Check patients understanding of tube feedings, aspiration
o Administer medication and fluid nutrition
2. Document two nursing diagnoses for this patient.
o Risk for aspiration as evidence by nasal tube and enteral feedings
o Risk for activity as evidence by respiratory condition (Cystic Fibrosis)
3. Document your priorities for care of this patient.
o Obtain vital signs and assessment of dietary and gastrointestinal
o Administer prescribed medication
o Administer prescribed fluid nutrition
▪ Check position first then aspirate and flush
▪ Keep at semi-fowler’s or higher to prevent aspiration
▪ Prevent more weight loss
o Provide patient education about aspiration, intake/output, BMI, tube
feedings, diagnostics and the nutrition importance to prevent malnutrition
o Due to his cystic fibrosis, it should also be a priority to keep his SpO2 up
—94% or higher
4. Describe the age-related considerations you will use when caring for Christopher
Parrish.
o This patient is a new adult so it is important to keep him informed on his
medical care and let him ask questions. It is important to provide him with
the education and give him options. His privacy is still an important factor
at this age so it is crucial for the nurse to maintain this. His is in charge of
his health now so run everything by him and get documentation stating
who information can be realsed to.
5. Referring to your feedback log, document the nursing care, including patient
education about nutritional needs and therapy, which you provided to Christopher
Parrish. Include his response.
o Reviewed patient information
o Reviewed diagnostics
o Reviewed orders
o Reviewed intake/output
o Arrived at bed side
o Performed hand hygiene
o Introduced myself
o Identified the patient
o Asked about allergies
▪ “No, I am not allergic to anything”
o Asked about any special diet that is prescribed by their doctor
▪ “Yes. A high fat, high calorie diet”
o education about diet provided
o asked patient how many bowel movements they have every day and about
the consistency
▪ “I usually have one or two and they are mostly formed but soft”
o Assisted patient to high sitting position
o educated the patient about positioning
o Attached and disconnected pulse ox
▪ 96%
o checked radial pulse
▪ strong, 85 bpm and regular
o measured blood pressure
▪ 116/70mmHg
o checked temperature
▪ 37.2 C
o Looked for normal breathing
▪ 12 breaths per minute and chest moving equally
o examined the patient’s head
▪ no obvious signs of airway obstruction, color is normal, and patient
is not sweating
o examined the patient’s abdomen and pelvis
▪ normal coloring, no sweating, normal elasticity of the skin
o examined patients legs
▪ normal elasticity of skin and color, no sweating
o examined patient’s arms
▪ normal elasticity of skin and color, no sweating
o examined back and spine
▪ normal elasticity of skin and color, no sweating
o Auscultated the lungs
▪ Breaths sounds are clear and qua bilaterally
o Reviewed MAR
o Reviewed patient log
o Reviewed clinical observations
o Compared medication label with MAR
o Gave a 5-tablet dose of pancrelipase orally
o Educated patient about medication
o Checked placement of NG tube
o Aspirated NG tube
o Flushed the NG tube
o Educated patient about tube feedings
o Asked the patient if they were getting the meals they needed on a daily
basis
▪ “Well, I am in college and sometimes I may not make it to the
cafeteria in time. That has happened a few times. I have snacks in
my room, but they don’t really replace a meal”
o educated patient about body mass index
o educated patient about diagnositics
o educated patient about risk of aspiration
o compared medication label with MAR
o started a 480mL tube feeding of fluid nutrition 1.5kCal/mL at 60 mL/hr.
o education patient about intake and output
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