Writing Progress Notes and ISBAR and Grading Rubrics
Read the case study and all of the rubrics:
- Organize and cluster data. Use Gordon’s Patterns to help determine client problems. Write a nursing diagnosis for each problem identified. HINT: The problems selected will have 1)a beginning, 2)a middle, and 3)an end
- Identify 2 different patient problems and write 2 different nursing diagnoses.
- Write One SOAPIE format note for one problem and
- Write One Focus (DAR) format note for another problem using the following case study information.
- HINT: The problems selected will have 1)a beginning, 2)a middle, and 3)an end. Think Nursing Process.
- Use the rubric provided to complete the assignment.
- Use times in the case study as appropriate. Be sure to include times where indicated or describe when the evaluation might have taken place if the time is not indicated. (For example, if pain interventions are implemented, the pain should be reevaluated 30 min – 1 hour after the interventions. Hint: the problems are not pain).
- Next, write an ISBAR to ask for something from the physician as if you were talking on the phone (all information is included in the case study). Remember, the purpose of communicating with the physician with this method. Be efficient. This is a dialogue you will have with someone over the phone. Write out everything!
- Upload the Nurse’s Notes and written ISBAR to moodle:
- Once you are done with the ISBAR, Record yourself saying the ISBAR on the moodle Poodle assignment. Remember to upload the recording once you are satisfied with it. A microphone is required for the recording – headphones with a microphone works!
- You may clarify with the instructor what vital signs mean, terminology that is unusual means, and assessment data meaning, etc.
- Finally, Submit the assignment:
- This is an individual assignment.
Case Study 2: today’s date. You are the nurse. This is background information.
Report was received from the off-going nurse at 0700 which included this information:
Situation: P.R., a 31 year old female who developed a high fever and was admitted to the local hospital a day ago.
Background: vital signs have been stable. The medex has an order for Tylenol 650 mg po as needed for fever every 3-4 hours and the client has not received any medications in the last 5 hours. She is scheduled for a chest x-ray at 1000 today.
Assessment: the patient is following the expected plan
Recommendations: continue with treatments and check lab values drawn this morning. Need to follow up about care upon discharge.
Key for abbreviations on the case study on next page:
- WNL – within normal limits (an expected finding)
- Low – lower than normal
- High – higher than normal)This is the end of the Background information
The nurse (you) assumes care (from this point forward is the assessment that you (the nurse) make):
Morning assessment reveals the following at 0800: Her vital signs are 112/68(WNL), Hr 134(high), Resp 24(high) regular rhythm, Temp 101 degrees F (high), oxygen saturation 92% (low) on room air. P.R. is cooperative; restless on bed rest and appears anxious. When the nurse questions the patient, P.R. states “it hurts to breathe.” The skin is warm and dry to touch, lungs with symmetrical expansion and crackles (abnormal) in the bases of the lower lobes bilaterally, heart rate regular rhythm during the assessment.
The nurse calls the doctor at 0820 and obtains an order for oxygen via nasal cannula at 2 liters per minute with humidity and to get a chest x-ray stat. The nurse encourages coughing and deep breathing.
At 0830 Tylenol is administered as ordered on the medex and the client is encouraged to drink 8 oz of fluids every hour.
Portable chest x-ray done at 0845 and the nurse auscultates faint crackles in lung bases bilaterally.
The next set of vital signs at 0930 finds the following: 110/80, HR 98, Resp 18, Temp 99 degrees F, oxygen saturation 98% on 2L O2 via nasal cannula.
