Chamberlain College of Nursing NR224 Fundamentals - Skills
Name& Date: Charting & Documentation Assignment
Joseph Page is an 80-year-old man admitted with a diagnosis of possible pneumonia. He complains of general
malaise and a frequent productive cough, worse at night. Vital signs are as follows: blood pressure, 150/90 mm
Hg; pulse rate, 92 beats per minute; respirations, 22 breaths per minute; and temperature, 38.5° C (101.3° F).
During your initial assessment he coughs violently for 40 to 45 seconds without expectorating. His lungs have
wheezes and rhonchi in both bases and are otherwise clear. He states, “It hurts in my chest when I cough.”
**** Differentiate between objective and subjective data in this case example. (10 points)
List Objective Data 1 Charting Documentation Assignment.docx List Subjective Data Revised 3/30/11 slp/jy/nlh Chamberlain College of Nursing NR224 Fundamentals - Skills
Name& Date: 2 Charting Documentation Assignment.docx Revised 3/30/11 slp/jy/nlh Chamberlain College of Nursing NR224 Fundamentals - Skills
Name& Date: You position Mr. Page in a semi-Fowler's position, encourage increased fluid intake, and give Tylenol 650 mg
by mouth (PO) as ordered for fever. One hour later the client is resting in bed. Vital signs are as follows: blood
pressure, 130/86 mm Hg; pulse rate, 86 beats per minute; respirations, 22 breaths per minute; and temperature,
37.7° C (99.8° F). He states he has been unable to sleep and feels very weak. You also note that his mucous
membranes are dry. His fluid intake has been 200 mL of water in the past 8 hours.
*** Use the given information to write a nurse's progress note using the PIE format. (30 points) P I E Several days later, following treatment with intravenous antibiotics, Mr. Page is feeling much better and
preparations are being made for discharge. He is to take Keflex 500 mg PO every 6 hours for the next 10 days,
continue to drink extra fluids, and get extra rest. He lives alone. Although he is generally cooperative, he does
3 Charting Documentation Assignment.docx Revised 3/30/11 slp/jy/nlh Chamberlain College of Nursing NR224 Fundamentals - Skills
Name& Date: not like drinking water or taking pills. He is to make an appointment with his physician for 1 week from today
and should call the physician if he develops symptoms of recurrence.
*** Write a discharge summary that is concise and instructive. (10 points) 4 Charting Documentation Assignment.docx Revised 3/30/11 slp/jy/nlh

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• 1506498948-Charting Documentation Assignment.docx