Question

Rewrite the following notes using the appropriate language for nursing documentation. Please Correct only where necessary.

a. D.K. is a 56 y/o African American male with a h/o HTN, high cholesterol, and arthritis; D.K is 5'10" and 300 pounds; pt. denies CP, SOB; pt. does not care about the risks of heart disease - he eats whatever he wants including fatty and salty foods; pt. told that he has to eat a low sodium low cholesterol diet if he doesn't want to die; pt. states that he has arthritic knee pain bilaterally - rates pain at 8/10; pt. looks like he is not in that much pain - given Tylenol for mild pain instead of 2 Percocet ordered for severe pain; patient told that obesity is causing knee pain.

b. J.B. is 40 y/o Caucasian male admitted for CP, r/o MI; pt. denies smoking but clothes and breath smelled like cigarette smoke so patient was obviously being dishonest; pt. also denies drug use but patient was lying about that too b/c he has signs of drug abuse - marks from heroin injections along both arms.; MD ordered morphine prn for chest pain due to low BP; pt. c/o CP at 0400 but not given prn morphine due to patient just seeking drugs; MD notified of patient lying about being in pain.

c. R.M. is a 95y/o admitted with pneumonia; h/o CVA - pt. is non-verbal; lives with granddaughter and her boyfriend; pt. has been physically abused - multiple bruises that definitely look like finger marks found on patient's arms bilaterally; RN asked granddaughter if her boyfriend is physically abusing pt. - she lied and said the patient fell and banged his arms on the kitchen table; RN notified social services that this is a clear case of elder abuse.

d. Mr. W. is a 76 y/o male admitted with COPD exacerbation; h/o anxiety and depression; pt. complaining that RN not answering call-light fast enough; pt. is being very unreasonable and impatient; pt. states that he is extremely anxious and needed his prn anti-anxiety med and says he is mad that the RN ignored the call light; pt. does not appear anxious - he is just complaining b/c he doesn't like to be alone for too long in his room; notified nurse manager that patient will likely write up a poor evaluation of the unit.

Answer 1

a. D. K is a 56-year-old African-American male with history of hypertension, high cholesterol and arthritis. D.K is 5'10" and 300 pounds. Patient denies chest pain and shortness of breath. Patient is not taking care of risks of heart disease. He eats both fatty and salty foods. Patient is informed that he has to eat a low-sodium, low-cholesterol diet if he doesn't want to die. Patient states that he has arthritis pain bilaterally on a pain score of 8/10.Patient looks like he is not in that much pain. Instead of 2 tablet of Percocet advised for severe pain, he has given Tylenol Tablet for mild pain. Patient also told that obesity is the cause of his knee pain.

b. JB is a 40-year-old Caucasian male admitted for chest pain to rule out myocardial infarction. Patient denies smoking but clothes and breath smelled like cigarette smoke. So patient was obviously being dishonest. Patient also denies drug use but patient was lying about that too because he has signs of drug abuse like marks from heroin injections along both arms. MD ordered Morphine p.r.n. for chest pain due to low BP. Patient complains of chest pain at 04.00 am but not given p.r.n. Morphine due to patient just seeking drugs. MD notified of patient lying about being in pain.

c. RM is a 95-year-old admitted with pneumonia having history of CVA. Patient is non verbal and lives with granddaughter and her boyfriend. Patient has been physically abused - multiple bruises that definitely look like finger marks found on patient's arms bilaterally. RN asked granddaughter if her boyfriend is physically abusing the patient? She lied and said the patient fell and hanged his arms on the kitchen table. RN notified social services that this is a clear case of elder abuse.

d. Mr. W is a 76-year-old male admitted with COPD exacerbation, history of anxiety and depression. Patient complaining that RN is not answering call light fast enough. Patient is being very unreasonable and impatient. Patient states that he is extremely anxious and needed his p.r.n. antianxiety medications and says he is mad that the RN ignored the call light. Patient does not appear anxious - he is just complaining because he doesn't like to be alone for too long in his room. Nurse Manager notified that patient will likely to write up a poor evaluation of the unit.