Individual Health Records • What different forms are used to keep patient information? What is the purpose of each form? Inside a patient’s medical chart there are many different forms that contain vast information concerning that specific patient. Each individual record will have a patient history form, which helps the physician, nurses or medical provider to better understand any past and hereditary illnesses, past surgeries, past injuries, and past pregnancies of a patient. This helps reduce the chances of providing unnecessary treatments or tests on a patient, and helps in diagnosis of a patient.
Assessment is a systematic process using a rational method of planning to identify a patient’s health and any actual or potential problems that need to be met and to provide interventions to meet those needs. (Berman et al, 2010) A comprehensive assessment establishes a database of information relating to the patient including visual observations during initial interview including, skin condition, cloths, hair, hygiene, demeanor and presence of pain etc. During the interview the nurse should gather family history and both subjective and objective data to establish baseline data as a reference point and an indicator to the effectiveness of interventions. (Berman et al, 2010) Subjective data is what the patient thinks, feels and believes and can also be referred to as the symptoms including itching, pain and worry or anxiety. Objective data is measured during the physical examination; it can be seen, heard, smelt, felt, observed, tested or measured against an excepted standard, including: skin color, bowel sounds, blood pressure, temperature, level of pain, urine analysis etc.
Unit Seven Workbook Assignment Chapter 12: Diseases and Conditions of the Reproductive System SYPHILIS A patient has been diagnosed with syphilis. The practice has printed instructions for patients diagnosed with this condition. The physician has instructed you to provide the patient with the printed information and to review it with her. How do you approach this patient-teaching opportunity? I would emphasize to the patient that with Syphilis infection, taking the prescribed course of antibiotics until completion is important.
Name: Topic: Reflective Essay Tutor: Date: Introduction Comprehensive Health Assessment is a successful clinical system usually used to provide comprehensive medical history for patients. The information collected becomes stored in one essential location for easy access in the future (Lenox (2007). Furthermore, a comprehensive health assessment is a process of steadily collecting and analyzing data to be used in making important judgments about patient’s health and other life processes for individuals and families. It includes critical analysis of data in order to come up with diagnosis and to recognize mutual problems. Health assessment plays a major role in the identification of individual’s strengths so that they are assimilated into healthcare planning.
Her history includes the recent start of a new blood pressure medication: lisinopril (Micromedex, 2013). The other medications Mrs. Baker takes are metformin, to control blood sugar (Micromedex, 2013), and hydrochlorothiazide, to eliminate excess fluid (Micromedex, 2013). When Mrs. Baker arrived in the ER, the nurse was able to ask a few questions but she then became unresponsive with difficulty breathing. The immediate goal of the emergency medical team is to stabilize the patient through restoration of homeostasis. Homeostasis is the ability of the body to maintain stability within its environment by managing external changes (Biology-online, 2013).
Jasmine Sackel Kaplan University Hs101 Unit 2 1. Define “standard of care.” How would appropriate “standard of care” be determined in this case? Sandra should be treated as any other patient with a head injury that would be appropriate standard care. Medical staff shouldn’t treat her any different because of her consumption of alcohol. Standard of care is a diagnostic and treatment process that a physician should follow for certain type of patients with illness or clinical circumstances.
• Both RN and LPN observe and communicate the outcomes of the delegated task. • RN and LPN Recognizing client characteristics that may affect the client’s health status. • They both promote a safe client environment. Differences: • LPN Determining priorities of care together with the supervising registered nurse or physician RN Prioritizes strategies based on client needs and goals • LPN does Planning episodic nursing care for a client whose condition is stable or predictable RN Identifies client needs and goals • LPN Providing health information to clients as directed by the supervising RN or physician or according to an established educational plan; RN Implements independent nursing activities consistent with the RN scope of practice • LPN Cannot assign care to RN; RN Assign nursing care to a LPN within the LPN scope of practice based on the RN’s assessment of the client and the LPN’s ability 2. According to Alfaro-LeFevre (2013) what are the two questions the nurse should ask to make decisions about his/her scope of practice and clinical decision-making?
Guideline 13: Nurses are accountable for validating the accuracy and completeness of the transcription of the order before administering the medication to the client. Electronic medication order entry systems are being implemented in practice settings. These systems allow prescribers to enter medication orders directly into the point of care system. The system automatically transcribes the orders and generates a MAR. One of the benefits of electronic order entry systems is that errors related to illegible writing, incomplete orders or misunderstandings resulting from verbal and telephone orders are decreased.
The paramedics that participated in the study felt that they were contributing valuable information and were proud to be a part of this research. Research can change the way healthcare providers treat their patients and can transform healthcare as a whole. As nurses engage in evidence-based practice, they can see that what they are doing has a firm basis in research and that they are not simply treating their patients based on
These efforts will not prevent every incident, but they can help reduce incidents. At Infectious Disease Specialists, nurses are exposed to blood or blood-contaminated body fluids daily. Wound care, peripherally inserted central catheters (picc) maintenance and removal, lab draws and peripheral intravenous catheters (IV’s) maintenance and removal are risk areas for nurses. “Hepatitis B virus (HBV) infection is the major infectious hazard for health-care personnel. Workers performing tasks involving exposure to blood or blood-contaminated body fluids should be vaccinated” (Centers for Disease Control and Prevention, 1997, p. 3).