Teamwork/Collaboration: Identify and use effective communication skills when working with inter-professional teams, documenting care, and reporting…

Question Answered step-by-step PRNU 1210 Skills 1Unit 3 – Nursing Process and Communication ToolsDAR Documentation AssignmentCourse SLO: Teamwork/Collaboration: Identify and use effective communication skills when working with inter-professional teams, documenting care, and reporting to appropriate team members. This assignment will provide students the opportunity to utilize the DAR method of systematic organization of information while writing nurses notes as part of a client’s HER/EMR. Below are 3 scenarios presented. Read each scenario, and then construct a nurse’s note in DAR format. Remember, D stands for Data (subjective and objective), A stands for Action (the action you took as the nurse – what did you do?), and R stands for Response (how did the patient tolerate or respond to the action provided?).  Case 1:Betty is a 62 year old female who comes to the clinic due to not feeling well and exhausted. No visible distress noted. Vital signs were obtained, temperature was 102.5 degrees F orally at 12:37. BP was 134/78, AP was 82 and respirations 24, nonlabored. Dr. Smith met with Betty and ordered blood cultures x2, a CBC and portable chest x-ray. The patient waited in the room while test results were obtained and provided 650mg of Tylenol orally at 1315. At 1400, Betty’s temperature came down to 100.2 degrees F orally. Lab and x-ray results are still pending. D:A:R:  Case 2: Brian is recovering from a total knee replacement two days ago. On assessment and looking at Brian’s orders, his activity level is to begin ambulating in small distances using a walker and stand by assistance. At 08:20 you assess Brian at the beginning of your shift, including his pain level, which is 4/10 knee pain. The dressing is intact and there are no signs of infection at this time. Brian has an order for Tylenol #3 5/325 1-2 tabs by mouth every 4 hours as needed for pain. You verify the last dose was given at 02:30 am. You administer 2 tabs of Tylenol #3 at the correct dose safely and deliver his breakfast. At 9:00 he states his knee pain is a 1-2/10. You successfully assist him to ambulate around his room and to the bathroom according to his orders. You then assist him to the chair while you change his bedding. He is pleasant and talkative while you tidy up his room.  D: A: R:  Case 3: Ed is a 62-year old post-op patient. He has been doing well with recovery until today, he states that “it is going downhill”. He complains that each time he gets up to use the bathroom that he gets dizzy. Educated Ed on dangling his feet before getting up next time and to call for assistance. Ed put on his call light, while assisting him to the bathroom. You reminded him to dangle his feet and to sit for approximately a minute or so prior to standing up. Educated on allowing his circulation needs to catch up to his body before arising. Ed voided 200mL clear, yellow urine. This trip to the restroom was better, however he is feeling a little more tired by the time he gets back to bed. Questioned Ed on his use of Incentive Spirometer and deep breathing exercises. He states, “I have been forgetting to do them”. You also notice that he is not wearing his TEDs as they were stuffed down under his blankets. You then assist putting on his TEDs and teaching how to use the IS.D:A:R: Health Science Science Nursing NURSING 1205 Share QuestionEmailCopy link Comments (0)