Question 3362

Question Case Analysis  Instructions: Read the scenario carefully and answer the questions based on the concepts of documentation and reporting.  Scenario:Mr. Anderson, an 80-year-old male, was admitted for back pain. He has a past medical history of hypertension. He told the admitting nurse that he has lost interest in many of his normal activities because of the constant pain.You read the following documentation entry by a previous nurse:8—Client is a complainer. I listened to him for 15 minutes with no success. BP210/90 and 180/70. P 72, R 18. 12—Refused lunch.2—Client fell out of bed.1. What guidelines were not used in this documentation?2. The nursing diagnosis for Mr. Anderson is Acute Pain. What would you expect to document?3. Using the following pieces of data for Mr. Anderson, sort them into a SOAP note:a. “I didn’t sleep last night”b. Positioned on side with pillows behind backc. Continues to need narcotic medication to progress toward goal of pain relief d. States pain is 8 out of 10e. “I feel better” (after interventions)f. Last medicated 5 hours previouslyg. Heating pad applied to lower back h. BP 210/90, P 72, R 18i. Add to plan of care to offer analgesic around the clock q4h versus prnj. 6/6/11 #1 Paink. “Sharp, stabbing pain in lower back that radiates to left leg”l. Medicated with ordered analgesic Health Science Science Nursing NURSING 103 Share QuestionEmailCopy link Comments (0)

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