Nursing Process, Documentation Assignment

Scope, Nursing Process, Documentation, and Communication
Written Assignment #1 35pts

Instructions: Complete the following questions independently of your peers. Be concise yet
detailed. You may use bulleted answers. Save this document as Assignment1Your name
Submission: Email completed assignment to kcarlson23@cvtc.edu
An elderly gentleman (E.B.) was transported from a nursing home to a hospital emergency
department with a chief complaint of shortness of breath. Upon further testing it was
discovered the patient was suffering from massive pulmonary emboli. The physician
explained to the patient that the prognosis was quite poor. The patient made it clear to the
physician that he did not want any heroic measures taken if he went into cardiopulmonary
arrest. The doctor documented thoroughlyhe mentioned the alert and animated state of
the patient, quoting the patient directly with regards to his wishes to be a Do Not
Resuscitate status while also noting the man's poor prognosis.
The next day, the patient was on bed rest and allowed to ambulate to the restroom with the
assistance of a CNA by approval of the RN. Upon discovering that the patient's oxygen
tubing was too short the CNA ran to get a longer length to walk with. As the CNA was
returning he heard family members in the hall calling for help. The patient was found on
the floor of his room unresponsive. The CNA called a code and immediately began CPR.
When the RN arrived she told the CNA to halt CPR because he was a DNR status. The
family members in the room, horrified, demanded that the patient receive full intervention.
The RN explained that the patient had specified to the doctor that he wanted no heroic
measures taken. The son countered that his father should receive life saving measures
because he was the power of attorney for his father and possessed the advanced directives
that had been filled out by him for some time prior to this hospitalization. Again, the RN
explained that the patient's current decision and the order entered by the doctor were
things she could not go against. The family sued the hospital, physician, and nursing staff.
1. (4pts) According to the Practice Acts and scope of nursing, what is the nurses
responsibility to:
The physicians orders?
The CNA?
The patient?
The family?
2. (5 pts)What are the four criteria used to determine if malpractice has occurred? Do you
believe malpractice occurred in this case?
3. (3 pts) Documentation was key in this event. What is the difference between DAR notes,
SOAP notes and CBE?
4. (10 pts) Communication with the family was a central issue in this case. Analyze the
following conversation using the table of techniques available on the course website.
Analysis should include interpretation of clients communication, technique used, and
identification of barriers (with alternative techniques that could have worked better
should have said), stages of communication (intro, working, termination). See Process
Recording Instructions and example
Client (elderly man E.B.) Nurse Analysis
Knocks and enters room.

Hello. My name is Carrie and
I need to discuss your recent
DNR status with you (Sits
down next to E.B. and
There is nothing to discuss. maintains eye contact)
(You notice him wringing his

hands, drawn facial
expression) Mr. B, you look
very anxious about the status.
What do you want?

(Continues to wring hands) I see here that your son is
POA for you and I would like
your permission to discuss
your DNR/CPR status with
him.
Huh? Well, whatever you say
to him, he wont agree with.
(fretful look on face)
(Lightly puts hand on his
forearm. Still facing patient)
Youre concerned about what
his response may be. Lets
talk about this.
Yes, I am. What if he
disagrees? (Looks at you
briefly, then looks down)
Oh, dont worry. He cant do
that. (laughing softly) You
make the decisions here.
Oh, OK.
I think you should let me talk

with him and explain things.
People trust nurses.
(maintaining eye contact,
nodding)
Silence for 5 seconds.

(Maintains eye contact and
hand on arm.)
Yeah, I dont know how to
bring it up. We have had our
differences in the past.
Good. Well I will talk to him
the next time he comes then.
Thank you!
Can I get you anything before

I leave? (nurse puts call light
next to patient)
No, Im good. Thank you.

(Smiles at nurse)
Alright. (nurse smiles and
leaves room)
5. (8pts) Complete the following care plans for E.B. Remember Problems are linked with
Outcomes and Etiology (Cause) is linked to Interventions
Altered Mobility R/T impaired breathing AMB bed rest, up with 1 assist
Interventions:
The nurse will:
The nurse will
Outcome (measurable, observable, dated):
The patient will:

The patient will:
Impaired Breathing R/T Mobility AMB Shortness of breath upon ambulation, requires O2
Interventions:
The nurse will:
The nurse will
Outcome (measurable, observable, dated):
The patient will:
The patient will:
6. (1pt)One hour after oxygen was administered, the nurse checks the patients oxygen
saturation and respirations. The action by the nurse is an example of what phase of the
nursing process?
a) Evaluation
b) Implementation
c) Planning
d) Diagnosis
7. (1pt)A nurse is therapeutically communicating with a client who was just diagnosed with
cancer. Which of the following techniques blocks effective communication with the patient?
a) Agreeing
b) Listening
c) Clarifying
d) Exploring
8. (1pt) Explain data clustering and how is it used in the nursing process.
9. (1pt) What is the role of the American Nurses Association?
10. (1pt)Which of the following parts of the nursing process is under the RNs scope of practice
only? Select all that apply.
a) Assessment
b) Planning
c) Diagnosis
d) Implementation
e) Evaluation

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Scope, Nursing Process, Documentation, and Communication

Written Assignment #1 35pts

The physicians orders?

Client (elderly man E.B.) Nurse Analysis

Knocks and enters room.

(You notice him wringing his

What do you want?

I think you should let me talk

Silence for 5 seconds.

Can I get you anything before

No, Im good. Thank you.

The nurse will:

The nurse will

Outcome (measurable, observable, dated):

The patient will:

The nurse will:

The nurse will

Outcome (measurable, observable, dated):

The patient will:

The patient will:

9. (1pt) What is the role of the American Nurses Association?

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