University of San Agustin

General Luna St., 5000 Iloilo City, Philippines

www.usa.edu.ph

COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS - DEPARTMENT OF NURSING

Name: Ann Nicole S. Barrera Year and Section: BSN-1N

A. Beginning her clinical preparation, the evening before, this morning Nurse
Rhona finds she
has been assigned to care for a 70-year-old male with complains of back pain and
has a
history of hypertension. She will be caring for him on his second hospital day.

1. What type of information can Melanie find in each of the following

documentation forms?
Why is that information vital to her preparation for care of her assigned client?

a) Admission Data Form

Nurse Rhona must check the client's Data Form in the Admission Data Form before
starting her next shift. This is done to confirm that she is caring for the correct patient and
is familiar with the essential procedures. An admission data form contains information such
as the patient's name, age, gender, residence, birth date and place, civil status, guardian,
emergency contact number, time and date of admission, health assurance, medical history,
and the results of any physical examinations performed. The document also includes the
reasons for the patient's admission to a hospital or other institution for inpatient treatment
and the initial orders for that patient's care.

B) Graphic Record
The patient's visual record contains information such the patient's body temperature,
pulse rate, respiration rate, blood pressure, BMI, and fluid intake and output. These are
necessary for Nurse Rhona to have in order to be prepared for the client she has been
given, to determine her client's past health, and to have some emergency supplies on hand.

C) Intake and Output

One of the responsibilities of personal care workers is to measure intake and output
(I&O), as well as to ensure that patients get enough food and drinks. The amount of fluids
that go into the body (intake) and the amount of fluids that come out of the body (output)
are measured by intake and output (I&O) (output). Both of these measurements should be
same. These vitals are crucial for Nurse Rhona to prepare for her client since they will help
her determine which fluids the client should continue to drink and which fluids they should
stop drinking. This is also capable of determining the client's present complexity and
whether it is related to her previous intake.

D) Medication Administration Record

A Medication Administration Record, or MAR, is a legal record of the drugs
administered to a patient at a facility by a health care practitioner (or eMAR for
electronic versions of the record). The MAR is part of a patient's permanent medical
record. The name of the medication, the dosage, the route of administration, the
frequency of administration, the date the prescription was written, and the expiration
date are all included in this order for the patient. Nurse Rhona will be better able to predict
when medicine orders should be provided and when medication should be
stopped when responding to her patient with this information.

Email: cn@usa.edu.ph | Tel. No.: 0999-997-1485 | Fax No.: (033) 337-4403

 University of San Agustin
General Luna St., 5000 Iloilo City, Philippines
www.usa.edu.ph

COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS - DEPARTMENT OF NURSING

B. Case Scenario: Mr. Polo, a 70-year old male, was admitted for back pain. He
has a
past medical history of hypertension. He told the admitting nurse, Nurse Rhona,
that
he has lost interest in many of his normal activities because of the constant pain.
You
read the following documentation entry by the previous nurse:
8 - Client is a complainer. I listened to him for 15 minutes with no success. BP =
200/90 and 180/70, PR = 72, RR = 18.
12 - Refused lunch.
2 - Client fell out of bed.

Answer the following questions:

1. What guidelines were not used in this documentation?
The time and date are two crucial rules that were overlooked in previous papers.
The precise date of the event of admittance was not noted in the nurse's record, nor
was the time, which is significant and based on a 24-hour military clock as the
indicated documentation, written in the document. Nurse Rhona would conceal the
fact that the entries were made in the morning or afternoon. Accuracy was not used
because the client's name and other identifying information were not stamped or
written on each page of the clinical record. As a result, we have no way of knowing
whether the papers in question actually belongs to the client. As a result, the
signature of the nurse was not used. The nurse had placed objects on the table that
had nothing to do with the patient's treatment, indicating a lack of appropriateness.
Furthermore, because there was little information on the reasons why the patient
declined lunch, completeness was not followed.

2. The nursing diagnosis for Mr. Polo is Acute Pain. What would you expect to
document?
Because Mr. Polo's nursing diagnosis is acute pain, the nurse should teach the
client about non-pharmacological pain treatments such visualization, distraction
tactics, suggested exercises, and relaxation techniques. To alleviate stress and offer
adequate pain therapy without relying too heavily on drugs.

3. Sort the following pieces of data for Mr. Polo into the following documentation
systems:
(*Note you may indicate your own time frame in making your
documentation.) a) SOAPIE
S:
• “I didn't sleep last night."
• BP = 200/90, PR = 72, RR = 18
• Sharp, stabbing pain in the lower back that radiates to the left leg. O:
• States pain is 8 out of 10
A:
• Acute Pain
P:
• Position the client on the side with pillows behind back
• Applying a heating pad to the lower back
• Medication with ordered analgesic - Nubain 5 mg IV for pain

Email: cn@usa.edu.ph | Tel. No.: 0999-997-1485 | Fax No.: (033) 337-4403

 University of San Agustin
General Luna St., 5000 Iloilo City, Philippines
www.usa.edu.ph

COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS - DEPARTMENT OF NURSING

I:
• Positioned on the side with pillows behind back
• Heating pad applied to the lower back
• Provide a medicated ordered analgesic- Nubain 5 mg IV for pain
E:
• "I feel better" (after interventions)
• Latest pain scale = 4 out of 10, BP 140/90, PR = 70, RR – 18

b) FDAR (Focus Charting)

• "I didn't sleep last night."
• Positioned on side with pillows behind back
• States pain is 8 out of 10
• "I feel better" (after interventions)
• Heating pad applied to lower back
• BP = 200/90, PR = 72, RR = 18
• "Sharp, stabbing pain in lower back that radiates to left leg."
• Medicated with ordered analgesic - Nubain 5 mg IV for pain
• Latest pain scale = 4 out of 10, BP 140/90, PR = 70, RR – 18

Date/ Time Focus Data/ Action/ Response

6/15/2019 Acute Pain D: •
7:00 AM "I didn't sleep last
night."
• States pain is 8 out of
10
• BP = 200/90, PR = 72,
RR = 18
• "Sharp, stabbing pain
in lower back that
radiates to left leg."
A: •
Positioned on side
with pillows
behind back
• Heating pad applied to
lower back
• Medicated with
ordered analgesic
- Nubain 5 mg IV
for pain
12:00 NN Acute Pain R: •
"I feel better" (after
interventions)
• Latest pain scale = 4
out of 10, BP
140/90, PR = 70, RR
– 18

Email: cn@usa.edu.ph | Tel. No.: 0999-997-1485 | Fax No.: (033) 337-4403