Chapter 30, Problem 5RP

Summary Introduction

To identify:

The information that should be documented by the nurse when interacting with Mr. J?

Case summary:

The nurse is caring for a middle-aged patient Mr. J, who had a past history of bilateral leg wounds, gunshot wounds, several surgeries, and paraplegia. Due to his long hospital stays, the staffs consider him as a manipulative and difficult patient. During his current surgical procedure for urinary diversion, the surgeon orders nothing by mouth for 2 or 3 days. During the clinical rounds, the patient demanded to be given food and told that his surgeon had told him to have food after the surgery. The nurse explained that his bowel is still under the effects of the anesthesia and still needs time to recover. The patient is not satisfied with the explanation and was sitting with a lunch tray when the nurse returned from her lunch break. The patient told he got it from the nursing assistants, the nurse immediately notified the issue to the surgeon. The nurse thought due to her lack of explanation, the patient is against the nurse and surgeon instructions.

Summary Introduction

To discuss:

Any alternative ways to describe this patient or is noncompliant appropriate?

Summary Introduction

To discuss:

About the word nonadherence? Whether these words have different connotations?

Summary Introduction

To identify:

The essential information that must be noted in the patient’s electronic record to support safe patient care?