* 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.
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.
On admission to hospital the patient is fitted with an identification tag which is usually placed on the patient’s wrist this should include their name, date of birth and patients hospital number. Before the patient is called to the anaesthetic room all anaesthetic equipment and machines must be checked and a record of the name of the person that checked it must be recorded along with the date. All other machines such as diathermy and suction machines must also be checked as well as other electrical equipment and theatre room lights. All drugs used for the planned case will also then be checked and prepared ready for the anaesthetist (Aitkenhead 2007). Upon entering the anaesthetic room the patient may be feeling a little venerable and unsure of what is happening therefore reassuring the patient and having good communication skills is important we should introduce our self and be able to explain what is happening and why, in a way that the patient understands (Oakley & Limborgh 2005).
ASSESSMENT: The protocol for the In-Reach team is to carry out a ‘Triage Assessment’. Triage has been described as the medical ‘process of assigning patients to appropriate treatments depending on their medical conditions and available medical resources’ (Liese, 1995 p. 48). The Community Care Act sets out that an assessment should be Needs
* First, read about the pathophysiology of your patient(s) medical diagnosis(es). You may want to start drawing your concept map at this time. * Review head to toe physical assessment, and transfer to care map the relevant physical findings that correlate with your patient’s (s’) medical diagnosis(es) * Review remaining objective data (labs, meds, etc.) and transfer relevant items to diagnostics
IV’s recognizing issues that arise with pt’s before crisis. Accurately evaluating condition and reporting to Admin of medication, dressing changes, using various medical equip .and supplies and pharmaceuticals. Experience includes EKG, Bladder Scan, Telemetry, IV, GT, Wound Vacs. Proper documentation within state and facility guidelines. Orientation and education of new RN’s and proper pt education.
3) Describe the common adverse reactions to medication, how each can be recognised and the appropriate action(s) required. Common adverse reactions are diarrhoea, skin rashes, sickness, facial swelling, blistering of the skin and wheezing. These can all be recognised by reading the side effects on medication packets or contacting a pharmacist. The appropriate action to take if a person supported is having an adverse reaction is to contact doctors/hospital so they can be treated appropriately. 4) Explain the different routes of medicine administration.
Though the most obvious is the process of drawing blood, there are other areas of knowledge that a phlebotomist is expected to master, and these will generally be tested on phlebotomy certification exams. Skills that phlebotomist need are Conducting interviews with patients, Understanding proper patient identification procedures, Taking a patient's vital signs, Assessing the patient's physical condition, Selecting venous access sites, Understanding the order of draw for multiple-tube phlebotomy, Understanding the color coding of tubes, Labeling collection tubes, Understanding patient care following completion of venipuncture, and Performing chemical tests. (www.education-portal.com,
Be sure to elaborate on what would be considered normal and abnormal (thus requiring further medical attention). Include any special tests that might be performed to evaluate the injury (i.e. x-ray, MRI, specific joint tests, etc.). 4. Treatment: This should explain the treatment of your injury, including immediate care and chronic care.
Once seen by the surgeon, a worksheet is created to indicate the desired surgical intervention. A chart is prepared and dated according to the surgeon’s request. The veteran as well as the chart is reviewed in the pre-anesthesia clinic where an interview is conducted with the veteran to determine anesthesia fitness. The chart is picked up by anesthesia and reviewed to determine if the veteran is a candidate for Lake City VAMC or Gainesville VAMC (the Gainesville VAMC is a larger scale facility with a teaching philosophy). The determination to facilitate the veteran in the Lake City VAMC places the chart in a holding area.