Nursing Sensitive Indicators Nurse sensitive indicators included in this case are Mr. J’s use of restraints, complications of pressure ulcers, and patient satisfaction. Had the nurse who was caring for Mr. J been aware about the risks of pressure ulcer development with the use of restraints, the beginning stage of a pressure ulcer could have been prevented. Better RN assessment of Mr. J’s restraints, repositioning Mr. J every two hours and a thorough skin assessment should be done at every shift. The NA should be instructed to notify RN if they see anything out of the ordinary with patients, such as the redness to the lower spine of Mr. J. The nursing staff assigned to Mr. J will need additional training about restraints as far as appropriate use of restraints and how to care for a patient who is restrained.
What should the nurse do next? Explain your rationale. o Administer oxygen through a non rebreather mask to ensure patient is getting enough oxygen to his brain. Then I’d establish two large bore catheter IV sites and prepare for surgical intervention as I’d suspect an epidural hematoma, which needs surgery to be removed. Managing the increased intracranial pressure would also be a necessity (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 1441).
The assessment of needs forms the background or starting point for further assessments against which improvements are compared. The assessment of needs is therefore the starting point for any decisions on care strategies. Assessment of needs in Asthma Physical: when my individual’s situation had worsened due to severe asthma attacks, her parents took her to the hospital. The doctor gave her a mobilizer which helps oxygen to pass through her blood in order to relax her. To prevent future attacks and to control them the doctor taught my individual’s parents how to do first aid such as helping the person to sit upright and loosening tight clothes and ensuring that the medication is taken during an asthma attack because it helps the service user to breathe better.
A) Measure the specific gravity of the drainage. B) Measure the spinal fluid pressure. C) Observe for a "halo" around a spot of drainage. D) Measure the quantity of the drainage. Nursing Plans and Interventions: The nurse applies a sterile nasal drip pad and initiates interventions to prevent increased intracranial pressure (ICP).
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.
Treatment plan “Approximately 28%–58% of individuals with heart failure (HF) suffer from cognitive impairment, commonly identified as difficulty with concentration and/or memory” (Bauer, Johnson, & Pozehl, 2011 p. 577). Mr. P needs a treatment plan that he will be able to adhere, considering his cognitive decline. His wife should be included in his treatment plan and will have to become a leader from now on. When Mr. P admitted to the emergency department, nurses provide basic care in order to sustain life. Nurses should be recording vital signs, order appropriate laboratory work ups, put Mr. P on oxygen via cannula, put him on I&O, administer prescribed medications, and strict daily weights.
HSC3052 – Undertake Physiological Measurements. Outcome 1.1 – Research and explain your responsibilities in relation to “Policy for the Recognition and Response to Acute Illness in Adults in Hospital”. Whenever a patient is admitted to hospital through Accident and Emergency it is essential that a number of baseline observations are taken in order to determine a patients progress whilst staying in hospital. The physiological measurements that should be recorded are respiratory rate, oxygen saturation, temperature, blood pressure, heart rate, and level of consciousness. Once a patient has been admitted to a particular ward, it is the responsibility of the Medical and Senior Nursing team to develop a monitoring system tailored to each individual patient in relation to their specific medical needs.
In the given case study, for instance, future provision of moderate sedation and additional backup must remain a mandatory exercise. Second, involves gathering of data and available evidence as a means of highlighting the occurrence of events, a behavior, or even condition (Clark &Taplin, 2012). According to most hospital regulations and ethics, when a patient begins to exhibit complications, it is upon the nurse and the ED physician to note the symptoms and offer appropriate treatment. Further examination of this scenario reveals a number of hazards/errors, i.e., shortage of qualified nurses, unfamiliar with appropriate medication dosages, the current procedure for conscious sedation was not followed, and the most fundamental hazard is the inability of the staff to prioritize and inform the administration (Nursing Supervisor) of the situation in the ED. The emergency department still failed to abide by medical ethics of practice.
The faster the patient receives treatment, the less damage will occur. The patient’s treatment will depend on whether the stroke is caused by a blood clot (ischemic) or by bleeding in the brain (hemorrhagic). Treatment focuses on restoring blood flow for an ischemic stroke or controlling bleeding for a hemorrhagic stroke. The doctor will use a computed tomography (CT) scan or magnetic resonance imaging (MRI) of the patient’s head to diagnose the type of stroke they have had. I recommendations the patient should have to avoid a stroke are the following: The patient should know their blood pressure and abnormal heartbeat that can increase stroke risk.
A series of education training of documentation was implemented to help reduce episodes of Medicare payment denials and self-protection through adequate documentation. Thus, I will discuss the impact of inadequate nursing documentation that leads to malpractice lawsuits. Purpose of Medical Record Documentation Understanding the purpose of medical documentation was the first step in teaching how to prevent inadequate documentations that leads to liability and malpractice lawsuits. Monarch (2007) supports the purpose of Medical Record Documentation as the following: • Substantiating the health condition or illness or presented concern for the patient. • Effective communication among health care staff.