Case Study 1: Patient Admission Concepts related to HLTEN512B Topic 1 Mrs. Gwen Jones is a 70 year old woman who has been admitted to your ward after arriving from her doctor’s surgery. Her GP has included a letter stating that he has assessed Mrs. Jones and requests she is admitted. She is feeling very unwell, with a high temperature, frequency of urination and burning when urinating. She appears slightly confused. She complains of back pain.
* 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
(The patient receives a medical history and physical examination no more than 30 days prior to, or within 24 hours after, registration or inpatient admission, but prior to surgery or a procedure requiring anesthesia services. For a medical history and physical examination that was completed within 30 days prior to registration or inpatient admission, an update documenting any changes in the patient's condition is completed within 24 hours after registration or inpatient admission, but prior to surgery or a procedure requiring anesthesia services.) In standard PC 01.02.05 “Qualified staff or licensed independent practitioners assess
Patient is visiting aunt and was brought into the ER and was mini-altered. Patient was given Geodon and Haldol to calm him and EKG was done. EKG showed A. fib with heart rate as high as 170. He was put on Cardizem drip and admitted for further evaluation. The patient denies symptoms of any chest pain, fever, nausea or vomiting.
1 Meet the Patient: Nancy Jackson, a 72-year-old Caucasian female, is brought to the Emergency Department at St. John's Medical Center, a Catholic facility, by her daughter, Gail. Mrs. Jackson, who asks the staff to call her Nancy, is complaining of right-sided weakness, a severe headache, and just not feeling well for the last 24 Hours. Clinical Manifestations: The Emergency Department (ED) nurse is completing the admission assessment. Nancy is alert but struggles to answer questions. When she attempts to talk, she slurs her speech and appears very frightened.
Fever, BP 88/59, HR 129, RR 26. RN anticipates initial orders for: 1. 2. Antipyretics and dopamine infusion CT scan of head & arm and drug screen Blood cultures, antibiotics, and rapid IV infusion IV fluids with MVI, thiamine, monitoring for signs of withdrawal, antipyretics Antipyretics and dopamine infusion CT scan of head & arm and drug screen 3. 4.
Physician/Practitioner Name: John Black, MD | | | | | | Physician/Practitioner ID Number: | | | | | | | | | | | | | | Patient Full Name: Beth Long | | Medical Record Number: | | | Patient DOB: 12/17/xx | | | | | | | | | | | | | | | | | Admission Date:04/26/xx | | | Discharge Date: 04/30/xx | | | | | | | | | | | | | Analyzed By: John Black, MD | | | | | | | | Date of Analysis: 4/30/XX | | | | | | | | | | | | | | | | | | | | | Deficiencies | | | | | | | | | | | | | | Signatures Missing | | | Missing or Inadequate Reports and/or | | | | | | Dictation Required | | | | | | | | | | | ______ | History & Physical | | | | ______ | History & Physical | | | __X____ | Consultation | | | ______ | Consultation | | ______ | Admission/Readmission Report | ______ | Admission/Readmission Report
Joint Commission Standard IM.02.02.01 (2013), “The hospital effectively manages the collection of health information. The hospital follows it list of prohibited abbreviations, acronyms, symbols, and dose designations, which include: U, IU, Q.D., QD, q.d., qd, Q.O.D., QOD, q.o.d, qod, trailing zero, lack of leading zero, MS, MSO4, MgSO4.” Current audit trends reflect that these abbreviations are still being used several times per month. Fire Drill – Nightingale Hospital requires that one fire drill is performed per shift, per quarter. The Joint Commission standard EC.02.03.03 requires this same
1. Discuss the nursing management of the postoperative patient who has undergone a total abdominal hysterectomy with bilateral salpingo-oophorectomy. * Determines patient’s immediate response to surgical intervention. * Monitor patient’s physiologic status. * Assess patient’s pain level and administers appropriate pain relief measures.
Visible shivering occurs as the body tries to increase temperature do to hypothalamus signaling. ____________________________________________________________________________________ The charge nurse audits Timothy’s chart including the vital signs during his hospitalization and notes the patients’ blood pressure has been recorded as 190/100, 90/50, 120/80 during the day shift yesterday. The charge nurse decides to investigate this variation by taking the patients BP to make sure he is stable. She also plans to speak to the nurse and aide who took the BP during the day shift yesterday. 1.