Question

I just need an example of how you would answer the question. Documentation for Danielle Young Bear.

• 1. Document your initial assessment data of Danielle Young Bear, including orientation, level of consciousness, pain assessment (including indicators of chronic pain), and vital signs.
• 2. In the nurses’ notes, document the medication reconciliation information for Danielle Young Bear. Include all prescription medications, OTC medications, herbal supplements, and dietary supplements. Note any drug–drug interactions.
• 3. Document the information you provided to Danielle Young Bear regarding adverse drug effects when combining medications.
• 4. Document the total amount of acetaminophen Danielle Young Bear ingested in the 24 hours before the scenario.
• 5. Document any referrals for Danielle Young Bear. Include who the patient was referred to and why.

Answer 1

1) Patient is alert and oriented

Thept. scores 15 on the Glasgow Coma Scale (GCS).

Pt. rates her pain at a 6, on a scale of 0-10. Pt. states that this painlevel is normal for her and that she’s been experiencing the pain for awhile now.

Pt. describes the pain as a dull achy feeling, sometimeswhen she moves it is a sharp pain.

Pt. explained that her pain worsenswhen she lifts heavy stuff and that her medications help her a lot withthe pain.

2.a.Cyclobenzaprine 5mg x 3 daily

b.Duloxetine 60 mg x 1 daily

c.Tramadol 50 x 4-6 daily

d.Hyrdrocodone 5mg/acetaminophen 325 mg x 4 daily

e.Nyquil 3 tbsp a day

f.Acetaminophen 500 mg x 4 daily g.Willow bark tea 1 cupi

.Drug—drug interations :

1.Hydrocodone and tramadol can cause seizures.

2.Hydrocodone containing acetteminophen and extra ecetaminophen were harmful to the pt.

Pt. stated that she is not allergic to anything.

Patient stated that she takes OTC medications. She mentioned that she’s taking cough medication for a cold which is Nyquil 3 tablespoonsper day. She takes acetaminophen 500 mg x 4 daily and sometimesshe may drink 1 cup of willow bark tea for the pain she’s experiencing.

3.It is important to only take the amount of medication that isprescribed. Remember to always take medication as prescribed and ifyou experience any side effects, report those findings to your doctor assoon as possible.

4) Danielle ingested 5950 mg of acetaminophen within the 24 hoursbefore the scenario.