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Documentation Assignments

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Christopher ParrishDocumentation AssignmentsChristopher ParrishDocumentation Assignments1. Document your focused gastrointestinal and dietary assessment of Christopher Parrish.a) Vital signs b) Inspect abdomen and auscultate bowel sounds c) Palpate abdomen and question about last bowel movement d) Inspect NGT tubing on the outside and assess placement via checking mouth and inspect nares as well e) Aspirate NGT for placement inspection and flush f) Ask patient’s eating habits and understanding of diet order g) Keep patient in semi or full fowlers position to reduce risk of aspiration h) Find out what patient knows about aspiration risk and educate as need i) Administer medication j) Administer fluid2. Document two nursing diagnoses for this patient.a) Impaired nutrition lower that body requirerment r/t disease and evidenced by loss of appetite and weight lossb) Risk for aspiration as evidenced by NGT3. Document your priorities for care of this patient.a) Obtain vital signs and assessment of abdomen and NGT b) respiratory status monitoring c) Maintain adequate nutrition by ensuring proper tube feeding is provided d) Administer prescribed medications as ordered e) Assessing tube correct tube placement before meals f) Assess bowel sounds continuously g) Provide required education of diet, aspiration and NGT as needed4. Describe the age-related considerations you will use when caring for Christopher Parrish.a) Establishing independence is important at this age so I will allow for Mr. Parrish to participate and suggest some of the needs that I could foresee b) Reinforce patient education about nutritional intake, BMI, and I&O c) Ensure patients understanding of feeding process and risk for aspiration5. Referring to your feedback log, document the nursing care, including patient education about nutritional needs and therapy, which you provided to ChristopherParrish. Include his response.a) Educated about Intake and Outputb) Educated about BMI c) Educated about diagnostics d) Educated about risk for aspiratione) Educated about tube feeding From vSim for Nursing | Fundamentals. © Wolters


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