First Nurse Narrative in Nursing CLass. Pleas help

So I am a new nursing student and our teacher has basically given us a scenario and we have to write whats important from it. THey are stressing to pick important parts and not take up the whole page. I am having a difficult time since its my first one.... any help would be greatly appriciated.


SITUATION ONE:


DATE: 5/19/1998

88 yr old female admitted 5/10/98 with fractured left hip. she had surgery , ORIF on left hip on 5/11/98. She progressed slowly because of pain in her left hip. Physical therapy is working with her to improve her ability to ambulate. Today you are her nurse at 0700 her vital signs are T-98.6 P-88 regular, R-22, BP 112/80. She is able to tell you correctly her name, the date, and where she is. You perform AM care , AROM on all extremities except LLE. AT 0800 she eats 1/4 breakfast , stating she feels "full" and c/o "my stomach hurts" holding her stomach and grimacing. SHe voids 150cc after breakfast . Suture line to Lhip in tact with no redness or drainage , eccymotic area over the Lhip area. Pedal pulses are palpable bilaterally, both feet are warm with capillary refill under 2 sec. Lungs clear bilaterally, abdomen firm, distended. Positive bowel sounds over all four quadrants. FLow sheet states last BM was 5/16/98 . AT 0805 you call DR jONES he orders MOM 30cc po x1, which you give at 0830. At 930 your pt has a large,hard brown BM. She states that she "feels much better". Her abdomen is soft, nondistended with active bowel sounds in all four quadrants.


SOAP NOTES
PIE NOTES
CHART BY EXCEPTION
>???


MAIN POINTS?
What do YOU think? Tell us what YOU think first.

Find it interesting they are using a 13-year old case...(at least change the dates!)Anyway, you need to add your thoughts on it first before we do you homework. Do you think the issue here is with her leg or with something else? What may have cause this 'something else?'

Certainly your instructor has given your class some idea of what's important and what's not in the scenario...? This is an exercise in critical thinking. Your post-op patient was constipated and now she's not. I would start this exercise with the question "why?"Good luck.

I've never been one to say "do your own homework" but this time I have to. Just pick out the important points, just like your instructions say. It's going to help your critical thinking skills (which is crucial in nursing) much better if you do it yourself.

Hey guys thanks . The question why this happened led me on the right way I wrote down the most important points and I have class now. I will post what I wrote then maybe see what I'm missing.