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NURS1101 Narrative Documentation Simulation And Rubric Copy

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John Marsh
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Narrative Documentation Simulation and Rubric copy

Louisiana College

Adult Health1 (NURS1101)

Mr. Green was admitted yesterday to the hospital for a bowel resection with re-anastomosis
secondary to colon cancer. He was admitted to the medical-surgical floor in stable condition at about
1500. Shift change came and went as usual. Mr. Green’s night shift assessment was WNL for
someone s/p major abdominal surgery. Recovery was progressing uneventfully until 0400 at which
time he spiked a temperature of 103.3. The night shift nurse called the physician, provided report and
received new orders, all of which have been documented and acknowledged.
Intake/output is totaled at 0600 and 1800. Whatever the amount is infused or taken PO or whatever
amount left in the foley catheter (or the JP drain or the suction canister or the specipan or the bedside
commode or …) between 0600 and 0700 or 1800 and 1900 is for the next shift, the oncoming shift, to
include in their fluid count.
The RN hung a new bag of fluids and the first antibiotic at 0600; the tech emptied the foley catheter at
that time thus closing out the night shift’s I and O documentation. The administration of new bag and
antibiotics is documented on the night shift MAR. The infusion of fluids and any urine collected
between 0600 and 1800 is yours to count.
You came on shift and received report at 0645. Your unit was short two nurses so your patient
assignment was an exceedingly heavy eight patients. Even the charge nurse has a half load of four
patients in addition to her other duties. No tech and no unit secretary were scheduled for today which
means you are down by a total four staff members.
You performed your head-to-toe assessment at 0730 and were able to document same below. FYI: It
is not necessary to re-document the shift assessment in narrative notes unless you just adore double
charting. The day went downhill from there. Everything you did during the shift other than the
assessment is written on hypothetical post-it notes or scraps of paper towel tucked into your pockets.
It’s 7PM and you have given report to night shift. Your greatest desire is to go home to a hot bath
and your favorite alcoholic product, not necessarily in that order. But you must first document 12
hours of patient care … so … you take your first bathroom break of the day and grab a cookie and a
coke. You sit down to document in the EMR and you realize that the hospital-wide EMR has crashed.
Can this day get any worse? You wonder why you gave up your lucrative position as a telemarketer
to become a nurse. You’re threatening to quit and become a Wal-Mart greeter.
Review the chart carefully and thoroughly. Consider the report you received this morning. All orders
are correct. Using orders and time cues contained within the patient chart pick up the scattered
pieces of your day and narratively document your care.

NURS1101 Narrative Documentation Simulation And Rubric Copy

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