* Assess patient’s pain level and administers appropriate pain relief measures. * Maintains patient’s safety(airway, circulation, prevention of injury) * Administer medication, fluid and blood component therapy, if prescribed. * Assess patient’s readiness for transfer to in hospital unit or for discharge home based on institutional policy. 2. Identify priority nursing care to prevent potential complications following this type of surgery.
In this case, the patient presented with a productive cough lasting over two. I used a holistic approach to assess the patient in general ensuring all systems relating to his presentation were covered and not rushing to a conclusion hastily which is recommended by Crumbie, (2006). The history taking was based on the Calgary Cambridge framework (Krutz, et al 2005) this involves five stages to help the nurse develop a holistic approach to the patient and empowers the patient to actively participate in their care. The first stage is initiating the session which involves preparing for the consultation, building a nurse patient rapport and gathering the reason(s) for presenting. The second stage is the information gathering stage exploring background information, exploring biomedical model and exploring the patient’s perspective.
Av: Doctors are responsible for prescribing medication. Managers are responsible for proving training, policy and procedures in handling and administrating medication, the staff team are responsible for giving and making sure that the service users are taking the medication. The service user is responsible for ensuring that they follow the medication guidance by the doctor. Avi: You can obtain information by asking friends, family, GP or any other people involved with the care of the service user. Medication can be obtained via GP.
The inpatient coder ensures that the data entered is relevant, indicating the reason that the patient was admitted, which involves the kind of illness and a breakdown of the treatment that was given (Henderson.) The inpatient coder uses the current version of ICD-CM classification for the most appropriate DRG assignment for assigning codes to diagnoses and procedures. They have to be able to determine the correct diagnosis and secondary diagnosis, identifying and assigning co-morbidities and complications and principle procedure codes. The inpatient coder is also responsible for selecting the proper DRG and Discharge Disposition Code. The impatient coder sends the documentation to HIM Operations for follow-up when Physicians documentation is not clear or straight forward.
The people involved in the RCA should be the people involved in the scenario: the RN (Nurse J), the LPN, the physician (Dr. T.), the emergency room manager, and a figure from administration (Chief Nursing Officer?). These participants should conduct a RCA to determine the causative factors that lead to Mr. B’s sentinel event. The first step would be to gather data about the situation. Mr. B’s presentation, vitals, health history, lab values, pain score, medications he already takes, and medications he received (amount, dose, and times) during the conscious
The NAON recommended that patients and their families should be provided with education about pin site care before discharge and that this should be supported by the provision of written instructions (Holmes ei a/2005). Information should be available in written, oral and visual formats and should be consistent (Lee-Smith et al 2001 ). In terms of risk, if it is considered that the patient and/or carer is not able to achieve the required competency to care for the pin site, then healthcare professionals with particular responsibility for pin site care should liaise with community nurses to maintain consistency and provide support (Lee-Smith et al 2001 ). Nursing accountability Medical staff often indicate their preference for carrying out pin site care. Healthcare professionals may include the pin site care regimen in the patient's notes.
Anesthetic nurses require their attention directly to the patient before, between and after surgery. There are a variety of anesthetic methods and anesthesia that could be administrated to the patient depending on the surgical needs. The anesthetist’s job is usually to help the patient become sedated in order to minimize any sensation of pain. Before the surgery the Nurse Anesthetist has the responsibility to go into the room of the patient that is being prepped for surgery and explain to them in detail what is going to be going on during the surgery. These advanced practice nurses then create a
If the consent is not given by a patient the practice, physician, or the healthcare worker can be held liable in a lawsuit. It is also important to show empathy and compassion to a patient to make them feel that they are welcomed. A healthcare worker should also know when to draw the line with a patient to avoid any kind of harassment issues or to make the patient feel uncomfortable. In any healthcare facility a patient’s need for care should be the main priority, and the healthcare worker should make sure that the priority is met. It has also been shown in the Medical Law and Ethics course that it is a must that all healthcare workers know and understand the legal
It is important that consent or refusal in a medical and/or scientific context be informed for all patients and research subjects. The purpose of informed consent is to enable the participant to be actively involved in their care, participating in the decision making process with a full awareness of any potential consequences of a treatment or a treatments refusal. Modern informed consent laws place a heavy emphasis on the value of individual human rights and patient autonomy by insisting that informed consent be obtained for all medical procedures. In the event that someone is physically or mentally incapable of consent, such as in patients suffering from later stage Dementia’s, a representative may be permitted to authorize certain procedures. The criteria for informed consent or refusal as stated in Chapter 6 of Ethical & legal issues in Canadian Nursing are as follows: * Consent must be given voluntarily.
As a health care professional trained in different approach, I assessed my client based on the theory and learning experience that I have had. The client was been diagnosed with dementia, limited mobility, and inadequate verbal communication. I undertook a full assessment to a client with a sacral pressure sore. Assessment using observation was been completed to the sacral area, and graded the level of pressure ulcer using the Braden scale. The nurse mentor was been informed about the type of dressing and intervention that should be provided to the client, along with the explanation with the rationale to the procedure that I have decided to use.