1 answer

Documentation Exercise Scenario: Question 54 refers to this scenario. You are caring for Dean Odell, a...

Question:

Documentation Exercise Scenario: Question 54 refers to this scenario. You are caring for Dean Odell, a 58-year-old male patie
Chapter 36 Administering Oral, Topical, and Mucosal Medications 299 HOSPITAL MEDICATION ADMINISTRATION RECORD Codes For Injec
300 UNIT 5 Medication Administration RM Patient ID BD Admit Physician Mission Regional Hospital Nurses Notes Date Time Figur
Chapter 36 Administering Oral, Topical, and Mucosal Medications 301 Patent Name: Mission Regional Hospital IDH Physicians Or
Documentation Exercise Scenario: Question 54 refers to this scenario. You are caring for Dean Odell, a 58-year-old male patient who was admitted on August 11, 2022. His date of birth is 06/06/64. His hospital ID number is 9607890. Mr. Odell has an order for digoxin 0.25 mg to be given at 9:00 a.m. daily. Today is August 12, 2022. You check his digoxin level and find that it is 2.0 ng/mL. When you check his pulse, you count it at 56 beats per minute. You hold the medication and notify the health-care provider. At 9:25 a.m. you speak with Dr. Marvel by telephone. He gives orders to stop the digoxin 0.25 mg, to give no digoxin for 2 days, and then restart it at 0.125 mg daily. 54. Document your actions on the MAR (Fig. 36.1), the nurse's note form (Fig. 36.2), and the health-care provider's order form (Fig. 36.3).
Chapter 36 Administering Oral, Topical, and Mucosal Medications 299 HOSPITAL MEDICATION ADMINISTRATION RECORD Codes For Injection Sites A-Loft Anterior Thigh H. Right Anterior Thigh B - Left Deltoid 1. Right Deltoid C. Lelt Gluteus Medius J. Right Gluteus Medius D. Loft Lateral Thigh K. Right Lateral Thigh E.Left Ventral Gluteus - Right Ventral Gluteus F. Left Lower Quadrant M. Right Lower Quadrant G-Loft Upper Quadrant N. Right Upper Quadrant ALLERGIES: DATE DATE DATE ADMIN DRUG -DOSE - ROUTE - FREQUENCY ORDERED REORD. TIME DATE DATE SIGNATURE / SHIFT INDICATES NURSE ADMINISTERING MEDICATIONS Figure 30.1 MAR (Wilkinson JM, Treas LS: Fundamentals of Nursing. Vol 1. 3rd ed. Philadelphia, PA FA Davis: 20161
300 UNIT 5 Medication Administration RM Patient ID BD Admit Physician Mission Regional Hospital Nurse's Notes Date Time Figure 36.2 Nurse's note
Chapter 36 Administering Oral, Topical, and Mucosal Medications 301 Patent Name: Mission Regional Hospital IDH Physician's Order Sheet Date Orders Figure 38.3 Health-care provider's order form. UTS care Lab W

Answers

MAR FORM

Date ordered Date record Drug-Dose_Route-Frequency Admin time Date Date Date
August 11 2022 August 11 Digoxin-2.0ng/ml-PO- 9.00am 11/08/2022
12/08/2022 Digoxin 0.25mg 9.00am DISCONTIUED FOR NET TWO DAYS (TILL14/08/2022)
15/08/2022 Digoxin 0.125mg daily 9.00am

Signature

Nurse administering the medications

2.In the nurses note form;

DATE;12/08/2022

9;00 am - Patient Mr..Dean Odell was assessed before the digoxin administration. His digoxin level is 2.0ng/ml and pulse rate 56 beats. Witheld the medication and informed health care provider.

9.25am - Telephonic conversation with Dr. Marvel. Advissed to stop dioxin 0.25 mg for the next two days (till14/08/2022) and restart it with0.125 mg daily.

3.

Health careprovider form;

Date;12/08/2022

09;25am ; Telephonic order from Dr. Marshell. Withold Digoxin 0.25mg till 14/08/2022 and restart on 15/08/2022 wth 0.125mg dose daily.

.

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