Question

Hi,

I just started my first nursing class and our question of the week is:

Module 2

The community health RN is caring for a family with a child who has significant developmental delays. The child is 9-years-old and exhibits the development of a 6-month old infant. She can move her extremities spontaneously, hold her head up and cry out occasionally. She has a gastrostomy tube for her medications and she receives continuous tube feeding via pump. She was discharged 2 days ago after a 5-day hospitalization for failure to thrive. During the hospital stay, the child’s tube feeding formula was adjusted to meet her growing needs. The community health RN is monitoring the child after discharge, following up on the child’s weight and the parent’s knowledge of the new feeding formula type, amount, and schedule. Today the child weighs 50 pounds. The child’s current weight represents a 2-pound weight gain since hospital admission.

The RN has chosen the NANDA-I nursing diagnosis of Ineffective health management r/t insufficient knowledge of expected growth and calorie requirements AEB parent states, “I thought the same tube feeding would be enough calories for a long time, I don’t know how to tell if the feeding should be adjusted.”

Initial Discussion Post:

• Create a narrative note to record this patient’s current health state

• Compare and contrast the narrative format to other documentation formats (PIE, SOAP, SOAPIE, SOAPIER, Focus Charting, or FACT system)

• Describe how an electronic health record (EHR) would be of benefit for the specific health care needs of this patient.

I am confused where to start. I reached out to my instructor and she said to make sure to touch on key points and add any information that may be needed.

Please help! I’ve never done a nursing note.

Answer 1