Nursing Process

Nursing Process.
The community health RN is caring for a family with a child who has significant developmental delays. The child is 9-years-old and exhibits the development of a 6-month old infant. She can move her extremities spontaneously, hold her head up and cry out occasionally. She has a gastrostomy tube for her medications and she receives continuous tube feeding via pump. She was discharged 2 days ago after a 5-day hospitalization for failure to thrive. During the hospital stay, the child s tube feeding formula was adjusted to meet her growing needs. The community health RN is monitoring the child after discharge, following up on the child s weight and the parent s knowledge of the new feeding formula type, amount, and schedule. Today the child weighs 64 pounds. The child s current weight represents a 2 pound weight gain since hospital admission.
The RN has chosen the NANDA-I nursing diagnosis of Ineffective health management r/t insufficient knowledge of expected growth and calorie requirements AEB parent states, I thought the same tube feeding would be enough calories for a long time, I don t know how to tell if the feeding should be adjusted.
Initial Discussion Post:

Compare and contrast narrative documentation with SOAP/SOAPIE/SOAPIER- style documentation.
Create a documentation entry to describe the community health nurse s first visit based on this scenario using SOAP/ SOAPIE/SOAPIER-style documentation. Students may embellish the scenario with additional patient information or parent s response to teaching if desired.

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Nursing Process