Question

Lab: Chapter 4 Discussion Question - Documentation and Informatics

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The nurse on the surgical intensive care unit is in the process of documenting care for her 38-year-old patient using the electronic health record (EHR). The patient was involved in a motor vehicle accident and suffered a crush injury to her right leg, which has been amputated below the knee. The patient is a single mother to a 5-year-old daughter and works as a waitress. The patient is conscious and has expressed fear as to how she will care for her daughter and if she will be able to keep her job. The patient cries often and has refused to speak with a psychologist to discuss her concerns.

As the nurse is documenting, her charge nurse tells her she must take her dinner break at this time. The nurse decides to bring her dinner back to the unit, so she leaves the computer logged into her account and minimizes the patient’s information, leaving a background screen saver picture visible. She tells her co-workers that she is still using the computer and that she will return quickly to resume charting. So that the computer does not log her off while she is away, she gives the unit clerk her password and asks the clerk to log her back in as needed.

1. Identify the clinical problem(s) in the case study.
2. Identify one patient problem and document using SOAP format.
3. With a focus on patient-centered care, explain how the nurse can encourage active participation from this patient in her care.

Answer 1

1.According to given case study patient problems are. * Patient involved in accident have crush injury on her leg underwent amputation. So her diagnosis was Crush injury ,her treatment was Amputation. With this patient may have surgical pain. *She was a single mother no one is there to take care of patient so she having fear and anxiety about her daughter . *She refusing to talk with Psychologist it indicates that she was in depression. So patient clinical problems are. 1. Pain . 2. Fear and Anxiety. 3.Depression.

2.SOAP is a method of documentation along with admission record. It helps to easy accessible information about information and provide quality care to patient. SOAP stands for S-Subjective data that is what patient complaint O- Objective data ,what we observed in physical examination ,include findings of physical and clinical assessment. A -Analysis include interpreting the results from physical assessment and laboratory test assessment and making differential diagnosis . P -Planning based on differential diagnosis to treat the patient.

Example according to patient data in SOAP format . *Patient involved in accident and had injury. She is single mother with one daughter. *By observation we can find that patient had crush injury on her right leg .She underwent Amputation which has pain. She was communicating with nurse that she is single mother ,she works as waitress,taking care of child ,if she didn't keep job , no one is there to take care so she had fear about her daughter. she was refusing to talk with psychiatrist. *By the given communication and diagnosis we can analyze that she was having pain ,fear and anxiety , Depression as differential diagnosis. *Plan for this patient include. 1.Provide comfortable position and pain reliving medication according to doctors order to reduce pain. 2. Provide psychological support to reduce fear and anxiety ,explain her that with artificial limb she can manage her work. 3. Provide diversional therapy to the patient.