NURS11325-Lab 1: Documentation Assignment

Instruction:

Clinical documentation is an important component within the practice of healthcare providers. Healthcare providers are required to make and keep records of their practice. They are accountable for ensuring that their documentation is accurate and meets the practice standards (CNO, 2008). “Documentation presents an accurate, clear and comprehensive picture of the client’s needs, the interventions and the client’s outcomes” (CNO, 2008, p. 6).

In this assignment, use DAR format to make a *type-written clinical progress note on an observation/assessment that you made on a client’s condition/behaviour in a case scenario. Choose only one case scenario out of the following three scenarios. Use the progress note for documentation, which is provided along with this assignment instruction. 

Assessment data, planning/actions and evaluation should be comprehensive and clear providing adequate information about client’s needs, appropriate interventions and client’s outcomes.

Refer to the documentation assignment rubric for specific evaluative criteria. 

DAR ((Problem-oriented Approach on Documentation) 

D –Data  Subjective and objective patient assessment date that supports the focus statement or describes observations of a significant event

1. Action   Immediate or future actions or plans of action or care based on the evaluation of assessment data

R- Response  The patient's response to the action taken.

*Note: Progress note should always be hand-written as per the CNO’s standards; however, given the current situation with Covid_19 pandemics, the assignment is altered to be completed in a type-written format just for the purpose of the assignment. Students must be aware that the progress note is always to be hand-written according to the CNO’s standards.

Scenario 1 – Fall 

You are assigned to Mrs. Jones for morning care. While assisting her with her morning bath you notice a purplish-blue bruise on her left hip. When you comment on it, she states that she fell yesterday when getting off the toilet, but didn’t tell anyone. She states the area is sore and moans when it is touched. Her mobility status stated on the care plan is Independent.

• Complete a DAR note on your observations, assessments and actions, as well as possible client response. Consider the date and time being the date and time that you are currently working on this assignment.

Scenario 2 – Nutrition & Feeding

At 0900, the residents at Collingwood Crossing LTC are brought into the central dining room for breakfast. Mr. Midgely is an 81-year-old gentleman with history of dementia, HTN, and type 2DM. He normally sits by himself at the corner table eating independently. Although over the last few months he has been having increased weakness, along with decreased mobility and needing more help with ADLs. You are assisting to feed another resident when you keep noticing Mr. Midgely falling asleep at the table, then waking up coughing his pocketed food. He is also sitting in a slouched position, with lots of food on his shirt/pants. You notify his nurse, who instructs you and another nursing student go over to check on Mr. Midgely.

• Complete a DAR note on your observations, assessments and actions, as well as possible client response. Consider the date and time being the date and time that you are currently working on this assignment.

Scenario 3 – Therapeutic Communication

Mr. Sherbino is a 76 year old who is in your LTC due to a recent stroke with left arm paralysis. He has been depressed with the recent changes in his life and is reluctant to get out of bed. Before dinner you ask him if he would like assistance to the wheelchair. He tells you that he doesn’t want to be a bother to anyone, and is upset that he no longer can do things independently. He agrees to get up to the wheelchair with your help. You note a red area to his left elbow and shoulder, he had turned onto the left side in the bed.

• Complete a DAR note on your observations, assessments and actions, as well as possible client response. Consider the date and time being the date and time that you are currently working on this assignment.

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Data Action Response (DAR) Documentation 

Subjective Data

Mrs. Jones reports sharp pain in the left hip region.  She explains that the pain was worst for the first hour after she fell.  The patient had to sit down for a while to allow the pain to reduce. She adds that the pain recurs whenever she touches the hip region.

Objective Data

On observation, there is a purplish-blue wound on her left hip. The patient groans every time the wound is touched and also exhibits guarding behavior. The patient cannot sit upright, and there is a foul odor produced around the bruise. Nonetheless, her blood pressure and heartbeat are within the regular rates. Her skin color around the wound is also normal, and she has good vision.

Action

Identifying biological, behavioral, and environmental factors may decrease the risk of falling according to (Guirguis-Blake et al., 2018). Advice Mrs. Jones to have regular light exercises that will strengthen her muscles. Strengthening leg and core muscles are vital towards maintaining sure footedness while walking. Encourage her to have adequate sleep. Prioritizing a whole night's rest every night is key to preventing falls. Regular sleep increases the patient's mental health and reduces movement disorder, resulting in slip and fall accidents.

Advice Mrs. Jones to be cautious every time she attempts to stand up and to do so gradually. Standing up too fast may result in lightheadedness, fainting, or dizziness. This is because the leg can have “fast sleep," therefore impending mobility and increasing the risk of falling. Mrs. Jones is also recommended to have a routine physical examination, including eye exams and regular blood work to identify deficiencies, grow fruit and vegetables, and limit sweets and fried foods. Mrs. Jones should also limit some risky behavior activities, for instance, consuming alcohol and climbing the ladder. Administer painkiller drugs such as analgesics to Mrs. Jones to help reduce the pain and inflammation. Recommend Mrs. Jones to report to any medical officers in case the pain resurfaces.

Encourage Mrs. Jones to report a fall if it happens again immediately. Early response to a fall may prevent complications or even death from severe organ damage or too much bleeding. Elevate the bruised region to reduce the pain and stop the expansion of the bruise. Inspect Rom of patient-related to fracture.  Encourage Mrs. Jones to avoid slippery surfaces and always wear the right recommended slippers when in the bathroom. Wearing socks without shoes or being barefoot can also result in falling.  Avoid dark or poorly lit rooms. The patient is advised to look out for uneven, rock, or curb surfaces while walking outside.

Response

The patient reports the reduction of pain around the left hip region. The bruise turned to a shade of yellowish-brown. It indicates that the bruise was healing.

References

Choi, S. D., Guo, L., Kang, D., & Xiong, S. (2017). Exergame technology and interactive 

interventions for elderly fall prevention: a systematic literature review. Applied Ergonomics, 65, 570-581.

Giurgius-Blake, J., Michael, Y., Perdue, L., Coppola, E., Beil, T., & Thompson, J. (2018). 

Interventions to Prevent Falls in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA, 319 (16);1705-1716

Haddad, Y. K., PharmD, MPH, Bergen, Ph.D., M. M., & Luo, F. P. (July 2018). Reducing Fall 

Risk in Older Adults. AJN, American Journal of Nursing, Volume 118 - Issue 7 - p 21-22 DOI: 10.1097/01.NAJ.0000541429.36218.2d

King, B., Pecanac, K., Krupp, A., Liebzeit, D., & Mahoney, J. (2018). Impact of fall prevention.

On nurses and care of fall risk patients. The Gerontologist, 58(2), 331-340.

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