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This is a graded discussion: 100 points possible due Jan 27 M2D1: Documenting Patient Care Note: You may not post to this discussion until week 2. The community health RN is caring for a family with a child who has significant developmental delays The child is 9-years-old and exhibits the development of a 6-month old infant. She can move her extremities spontaneously, hold her head up and cry out occasionally. She has a gastrostomy her medications and she receives continuous tube feeding via pump. She was discharged 2 days ago after a 5-day hospitalization for failure to thrive. During the hospital stay, the childs formula was adjusted to meet her growing needs. The community health RN is monitoring the child after discharge, following up on the childs weight and the parents knowledge of the new feeding formula tube for tube feeding type, amount, and schedule. Today the child weighs 50 pounds. The childs current weight represents a 2-pound weight gain since hospital admission. The RN has chosen the NANDA-I nursing diagnosis of Deficient knowledge r/t change in growth and calorie requirements AEB parent states, I thought the same tube feeding would be enough calories for a long time, I dont know how to tell if the feeding should be adjusted. Initial Discussion Post: Create a narrative note to record this patients current health state. Discuss why accurate documentation is critical in healthcare. What information is crucial to include in a handoff report? Discuss the role of nursing informatics in this scenario.
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