Eva Madison (Complex)
Documentation Assignment: Eva Madison (Complex)
1. Document the patient history you obtained for Eva Madison.
A 5 yr old female patient has vomiting and diarrhea for 3 days, lack of appetite. Condition
progressed beyond mild dehydration. Patient l
2. Document your initial focused assessment of Eva Madison.
Eva was cooperative throughout assessment. Took vitals with no issues. Patient skin was pale
and cool, mucous membranes dry , no known allergies
3. Referring to your feedback log, document the nursing care you provided and
Eva Madison's response.
I introduced myself, washed my hands, and identified the child and relatives in the room. I asked
for any allergies, the parent replied No. I assessed Evas breathing of 30 breaths per min with
equal chest rise. I listened to hear lungs breath sounds clear and equal bilaterally anterior and
posterior. I auscultated her heart and heard normal heart sounds with no murmurs. I attached a
continuous pulse oximeter as per MD orders. I attached a NIBP cuff, measuring Eva temperature
of 37.2 celsius. I assessed her IV site and no swelling, infiltration, bleeding or drainage was seen.
The dressing was dry and intact. I asked Eva if she had any pain and where, her response was
“Yes, I have some pain in my tummy”. I offered her a toy for comfort. I obtained a sample for
stool culture per MD orders. I started infusing DS 5% in 0.45% NS at 62 mL/hr per MD orders. I
provided patient education to Eva and parents. I assessed her breathing and observed 31 breaths
per minute equal chest rise. I phoned the provider and performed a patient handoff.
4. Document the patient teaching that you would provide for Eva Madison and her
parents before discharge.
Patient education I would incorporate in my plan of care is to teach Eva and her parents that diet
and diet progression is important. I would recommend pedialyte to improve her electrolyte
balance, in addition to a BRAT diet (banana, rice, applesauce and dry toast) to aid in easing her
stomach while also providing nutrients. Parents should monitor for worsening symptoms such as
worsening of diarrhea, no urine release, fever and lethargy.
Guided Reflection Questions: Eva Madison (Complex)
Opening Questions
Documentation Assignment: Eva Madison (Complex)
1. Document the patient history you obtained for Eva Madison.
A 5 yr old female patient has vomiting and diarrhea for 3 days, lack of appetite. Condition
progressed beyond mild dehydration. Patient l
2. Document your initial focused assessment of Eva Madison.
Eva was cooperative throughout assessment. Took vitals with no issues. Patient skin was pale
and cool, mucous membranes dry , no known allergies
3. Referring to your feedback log, document the nursing care you provided and
Eva Madison's response.
I introduced myself, washed my hands, and identified the child and relatives in the room. I asked
for any allergies, the parent replied No. I assessed Evas breathing of 30 breaths per min with
equal chest rise. I listened to hear lungs breath sounds clear and equal bilaterally anterior and
posterior. I auscultated her heart and heard normal heart sounds with no murmurs. I attached a
continuous pulse oximeter as per MD orders. I attached a NIBP cuff, measuring Eva temperature
of 37.2 celsius. I assessed her IV site and no swelling, infiltration, bleeding or drainage was seen.
The dressing was dry and intact. I asked Eva if she had any pain and where, her response was
“Yes, I have some pain in my tummy”. I offered her a toy for comfort. I obtained a sample for
stool culture per MD orders. I started infusing DS 5% in 0.45% NS at 62 mL/hr per MD orders. I
provided patient education to Eva and parents. I assessed her breathing and observed 31 breaths
per minute equal chest rise. I phoned the provider and performed a patient handoff.
4. Document the patient teaching that you would provide for Eva Madison and her
parents before discharge.
Patient education I would incorporate in my plan of care is to teach Eva and her parents that diet
and diet progression is important. I would recommend pedialyte to improve her electrolyte
balance, in addition to a BRAT diet (banana, rice, applesauce and dry toast) to aid in easing her
stomach while also providing nutrients. Parents should monitor for worsening symptoms such as
worsening of diarrhea, no urine release, fever and lethargy.
Guided Reflection Questions: Eva Madison (Complex)
Opening Questions
