Christopher Parrish
Documentation Assignments
1. Document your focused gastrointestinal and dietary assessment of Christopher
Parrish.
On 04/02 at 2315 Mr. Parrish had normal bowel sounds in all four quadrants, abdomen
was soft and nontender. Abdomen was not distended. Patient did not report any pain during
assessment of abdomen. Patient reported that his last bowel movement “today and that it was
soft and formed.” Patient has Nasogastric tube in right nares and is secured with tape. The
patient has no discomfort in regards to the NG tube. Right nares are free of irritation. The NG
tube was aspirated and returned 30 mL of gastric fluid. NG tube was also flushed with 30 mL
of normal saline and met with no resistance or complications. Patient is on high fat, high
calorie regular diet. Patient reported that he “was just not that hungry” when questioning
about his intake and output today. Patient only had a few bites of a chocolate milkshake.
Patient also stated that while at college he does frequently miss meals due to lack of time but
tries to replace them with small snacks. Patient also reports that he “lost about 13.2 lbs. since
beginning college”
2. Document two nursing diagnoses for this patient.
1. Imbalanced nutrition: less than body requirements related to decreased albumin
and protein levels secondary to Cystic Fibrosis as evidence by...
i. Patient stated “he does not have an appetite”
ii. Upon assessment patient had was receiving tube feedings
iii. Patient stated that he “lost 13.2 lbs. since beginning college”
2. Ineffective coping related to increased stress secondary to first year at college as
evidence by...
i. Upon assessment patient acted withdrawn when engaging in conversation
regarding his health
ii. Patient stated that he “did not have any appetite”
iii. Patient stated that he “felt tired all the time”
3. Document your priorities for care of this patient
1. Establish a therapeutic relationship with my patient to help better educate him on
his diet in regards to his Cystic Fibrosis. Also, to help cope with the stress of
college such as moving to a new environment and heavy course load.
2. Monitor that my patient is receiving proper nutrition via his nasogastric tube and is
gaining more weight and his albumin and protein levels are returning to a normal level.
From vSim for Nursing | Fundamentals. © Wolters Kluwer
This study source was downloaded by 100000838234991 from CourseHero.com on 10-17-2022 12:40:00 GMT -05:00
https://www.coursehero.com/file/59331157/Clinical-Documentation-and-Reflection-for-Christopher-Parrish-1pdf/
Documentation Assignments
1. Document your focused gastrointestinal and dietary assessment of Christopher
Parrish.
On 04/02 at 2315 Mr. Parrish had normal bowel sounds in all four quadrants, abdomen
was soft and nontender. Abdomen was not distended. Patient did not report any pain during
assessment of abdomen. Patient reported that his last bowel movement “today and that it was
soft and formed.” Patient has Nasogastric tube in right nares and is secured with tape. The
patient has no discomfort in regards to the NG tube. Right nares are free of irritation. The NG
tube was aspirated and returned 30 mL of gastric fluid. NG tube was also flushed with 30 mL
of normal saline and met with no resistance or complications. Patient is on high fat, high
calorie regular diet. Patient reported that he “was just not that hungry” when questioning
about his intake and output today. Patient only had a few bites of a chocolate milkshake.
Patient also stated that while at college he does frequently miss meals due to lack of time but
tries to replace them with small snacks. Patient also reports that he “lost about 13.2 lbs. since
beginning college”
2. Document two nursing diagnoses for this patient.
1. Imbalanced nutrition: less than body requirements related to decreased albumin
and protein levels secondary to Cystic Fibrosis as evidence by...
i. Patient stated “he does not have an appetite”
ii. Upon assessment patient had was receiving tube feedings
iii. Patient stated that he “lost 13.2 lbs. since beginning college”
2. Ineffective coping related to increased stress secondary to first year at college as
evidence by...
i. Upon assessment patient acted withdrawn when engaging in conversation
regarding his health
ii. Patient stated that he “did not have any appetite”
iii. Patient stated that he “felt tired all the time”
3. Document your priorities for care of this patient
1. Establish a therapeutic relationship with my patient to help better educate him on
his diet in regards to his Cystic Fibrosis. Also, to help cope with the stress of
college such as moving to a new environment and heavy course load.
2. Monitor that my patient is receiving proper nutrition via his nasogastric tube and is
gaining more weight and his albumin and protein levels are returning to a normal level.
From vSim for Nursing | Fundamentals. © Wolters Kluwer
This study source was downloaded by 100000838234991 from CourseHero.com on 10-17-2022 12:40:00 GMT -05:00
https://www.coursehero.com/file/59331157/Clinical-Documentation-and-Reflection-for-Christopher-Parrish-1pdf/
