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NURS2204 – Nursing Foundations 3 Documentation Assignment. Learning Objectives Demonstrate accurate documentation of pertinent information following wound assessment and care. CLPNA Competencies D-3-2 – Demonstrate knowledge and ability to ensure timely, accurate, objective, concise and complete documentation. D-3-3 – Demonstrate knowledge and ability to document and report according to practice setting and employer requirements. Instructions Your instructor will assign you a scenario which you will use to complete your documentation. Please refer to the Documentation Assignment Rubric for guidance on how the assignment will be graded. The scenario can relate to any of the skills which we have learned so far in the lab. You will complete an appropriate assessment of the images that are provided in the scenario. Please download the blank DARP template on D2L and submit your assignment typed, not handwritten. You may submit it in .docx or PDF format, please do not submit anything from Pages as we will not be able to open your document. You are to complete your documentation individually and submit it into the assignment Dropbox on D2L prior to the due date. Please refer to the PN handbook for information regarding late assignments and penalties. Updated Nov 2023 – N. Dumais. NURS2204 – Nursing Foundations 3 Documentation Assignment. Updated Nov 2023 – N. Dumais. You are the practical nurse learner caring for Thomas Morello. He was admitted to your respiratory unit following a chest tube insertion for a hemothorax in the left lung. He has the following orders for chest tube maintenance: Chest Tube Maintenance Requested: Today’s date Status: Active Chest tube #: 1 Location: Left Posterior. Suction: -20 cmH2O continuous- can come off suction for ambulation/procedures. Action: Dressing changes daily, as per nursing policy/procedure. The time is 1030 and you are ready to complete Thomas’ chest tube dressing. You ask him to rate his pain and he states “3/10, but I only have pain if I take a deep breath.” He declines pain medication when its offered. You complete a relevant patient assessment and assessment of the atrium (see image below). You do not note any air leak or tidaling on the Atrium. Assessment of the old dressing – there is Sanguinous, dark red, partially dried drainage present with no odour. Jelonet has 0% saturation. 1st T-sponge has 10% saturation, second T-sponge has <5% saturation, 4x4 gauze has 0% saturation. Please complete an assessment on the following image. Morello, Thomas DOB- 1965/May/29 Hosp # 3359401405 NURS2204 - Nursing Foundations 3 Documentation Assignment. During the dressing change, Thomas asks you why the dressing needs to be changed every day "they keep telling me I'm not bleeding from where the tube is, why do they have to change it?" You respond to his , please provide a relevant answer in your documentation and one other relevant teaching. After the procedure, Thomas states his pain is unchanged. You finish your task and leave the room to document. Updated Nov 2023 - N. Dumais. SCIENCE HEALTH SCIENCE NURSING

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