Reference no: EM133563937

Part A- As a Student nurse, describe short nursing note based on an example of care provided in the scenario below. Consider the information presented in the episode of care.

Scenario: Today, you have been assigned to a new patient, Mr. Johnson, who has just been admitted to the ward with pneumonia. When you arrived at Mr. Johnson's room, you introduced yourself and explained your role in his care. You then proceeded to take his vital signs, including his blood pressure, temperature, and oxygen levels. You noticed that Mr. Johnson's breathing was laboured and elevated, and his temperature was slightly elevated. Whilst not yet in a range that you would want to call a rapid response, you are concerned that Mr Johnson is showing early signs of deterioration.

You decide to telephone the doctor in charge of Mr. Johnson's care to report your observations and concerns, and the doctor orders an oral medication to help reduce his fever. You prepare the medication and explained to Mr. Johnson how and why to take it.

You perform the rights and checks of medication safety, then as you hand him the medication, you notice a fearful expression on Mr. Johnson's face. You gently reassured him and help him with a glass of water to take the medication. You stay with Mr. Johnson for a few more minutes, making sure he is comfortable and answering any questions he has.

Before leaving the room, you document observations and the medication administration in Mr. Johnson's chart.

Part B- ( Reflective writing - 'The Do's and Don't's of Documenting', and EXPLAIN in a mini reflection how you have applied guidelines of high-quality documentation to your nursing note. Mention At least 1 high quality, peer reviewed reference from year 2018 is required to support your statements as to how your example is in line with evidence-based best practice in documentation.