Compose a documentation entry to describe the community health nurse’s first visit based on this scenario using your chosen documentation format.

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 tube for 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 child’s tube feeding formula was adjusted to meet her growing needs. The community health RN is monitoring the child after discharge, following up on the child’s weight and the parent’s knowledge of the new feeding formula type, amount, and schedule. Today the child weighs 64 pounds.

The RN has chosen the nursing diagnosis of imbalanced nutrition, less than body requirements r/t insufficient nutritional intake AEB an 8-pound weight loss over 2-month period

 

Initial Discussion Post:

  • Choose one (1) documentation format (Narrative, PIE, SOAP/SOAPIE/SOAPIER, or Focus Charting).
  • Explain your choice and include information about why this format is appropriate for this scenario.
  • Compose a documentation entry to describe the community health nurse’s first visit based on this scenario using your chosen documentation format.
  • Students can create additional data elements to include in the documentation.

Base your initial post on your readings and research of this topic. Your initial post must contain a minimum of 250 words. References, citations, and repeating the question do not count towards the 250 word minimum.

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