...education 4. The right evaluation 5. The client’s right to refuse The right client needs to be ensured by checking the wrist band, and by checking a second piece of identification. This could be a picture on the chart, or a case number that is both on his chart and wristband. This must be done before any medication is administrated. The right drug means that the client receives the drug that was prescribed by a physician (MD), dentist (DDS), podiatrist (DPM), or an advanced practice nurse with the license to write prescriptions (APRN). The use of computerized systems to record medications has helped to decrease medication errors, because nurses are not trying to read written forms of the prescriptions. Dr.’s can electronically add a new medication order to a pt. chart from any location. If there is a phone order or verbal order it must be cosigned by the prescribing physician within 24 hours. The components of a drug order are as follows: · Date and time the order is written · Drug name (generic is preferred) · Drug dosage · Route of administration · Frequency and duration of administration (e.g, x 7 days, x 3 doses) · Any special instructions for withholding or adjusting dosage based on nursing assessment, drug effectiveness, or laboratory results · Physician or other health care provider’s signature or name if TO or VO ·...
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...Instructions Complete the medical abbreviations chart. (Note that the medical abbreviations are the same as those highlighted in yellow in Jane Dare’s Health Record). In the second column, list what each of the individual letters in the abbreviation represents. In the third column define the context or meaning of the term that the abbreviation represents. Use simple terms. Finally, in the far right column, identify the source document. For example, face sheet, discharge summary, progress notes, or x-ray report. Abbreviation | Letters Represent | Context Definition or Application within the Patient’s Chart | Source Document | 1. ICD | International classification of disease | Jane dare’s disease | Admission summary | 2. CM | Cardiomyopathy | Structural or functional disease of heart muscle | Admission summary | 3. N/A | N- NotA- Applicable | Not availableNo answer | Admission summary | 4. ER | E-EmergencyR- Room | Arrived at emergency room | History and physical | 5. C/O | Complains of | Reason for Jane to go to the ER | History and physical | 6. SOB | Shortness of Breath | Having difficulty breathing | History & physical | 7. mg | Milligrams | 1/1000 of a gram | 25mg capoten orally 3x a day | 8. po | Peri/osteum | Takes furosemide 40mg orally daily | Medications/ history & physical | 9. tid | Times interval difference | 25mg capoten by mouth 3 times a day | medications | 10. qd | Quantum dot | MOM 30cc daily by mouth...
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...BETTER ACCURACY IN WRITING AND DISPENSING OF PRESCRIPTIONS Anita Walsh Western Governors University Prescriber writing errors happen in all forms, places and types. From what the medical staff thinks, the prescriber has prescribed and calls in to the local retail pharmacy, hospital pharmacy, or even the in house pharmacies: adding that the pharmacy processing these uncorrected prescriptions that end up getting to patients. If someone does not catch these errors whether it is the pharmacist, being asked by the patient, why there receiving this drug, because they thought doctor said something else. Therefore, the pharmacist may check it. In a hospital, setting a nurse may look at a chart and question the drug, and call and verify. However, many times no one questions it until the patient has a reaction, or what he or she are being treated for gets worse. Along with communicating with the prescribers, their offices, hospitals, patients, pharmacists also have to be up to date on the all laws, federal and state, and be watchful for those that try to fill fraudulent or altered scripts. Research suggests that there would be significant benefits if all prescribers would follow the same procedures for writing prescriptions, such as using computer generate prescriptions or E-scribe, because there would be a decrease in prescription writing errors, pharmacy mistakes and prescription fraud. Pharmacies call prescribers offices to clarify prescriptions information, on average...
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...* * Fundamentals of Nursing (NSG 1355) Care Plan * * * ------------------------------------------------- Admission History * ------------------------------------------------- * ------------------------------------------------- Patient Information: Age: 60 Gender: Male Weight and Height: 390 lbs, 76” BMI: 47.47 (Morbidly Obese) * ------------------------------------------------- * ------------------------------------------------- Primary Language: English Religion: Latter-Day Saint Culture: Caucasian * ------------------------------------------------- * ------------------------------------------------- Resusiciation Status: Full Code * ------------------------------------------------- * ------------------------------------------------- ...
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...MANAGEMENT OF THE CHILD WITH FEVER Aim To manage the symptoms of fever so as to reduce the child's discomfort. Key points 1. Fever is a sign of illness/inflammation. Uncomplicated fever is relatively harmless, and is fact an important immunologic defence mechanism 2. The cause of the fever should be the focus of treatment. Indications to intervene 1. The intervention has the potential to increase the child’s comfort level (or decrease their discomfort). 2. The purpose of intervening can be clearly identified. 3. Reduction of parental anxiety could arise from the intervention. 4. Any harm that might result from intervening (e.g. increased discomfort or risk of liver damage) has been balanced against the expected benefits. 5. Symptoms associated with fever which may respond to nursing intervention include: • Flushing of the skin • Skin feels warm to touch • Thirst • Sweating • Headache • Weakness and aching of body parts • Irritability or restlessness • Dehydration associated with vomiting and or diarrhoea 6. In the case of high temperatures disorientation and convulsions may also be observed PROCEDURE To enable the effectiveness of interventions to be assessed, a baseline temperature should be taken before implementing any care. 1. Assess the need to intervene Interventions should be directed toward reducing the child’s discomfort, not the fever. Interventions should always be assessed in terms of potential risks. 2. In the first instance: • • • Remove excess clothing or wrappings...
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...Evidence-Based Fever Management Teaching Intervention for Emergency Room Nurses Alonya Elgrably Dominican University of California E-MAIL: ERSPRSTAR@gmail.com March 04, 2010 Signature Page This capstone project is assembled under the direction of the candidate’s program advisor and approved by the Director of the Master’s program and the Chair of the Nursing Department. It has been presented to and accepted by the Faculty of the School of Nursing, Dominican University of California, in partial fulfillment of the requirements for the degree of Masters of Science, Nursing. ______________________________________________ __________________ Candidate Date ______________________________________________ __________________ Advisor or Director Date ______________________________________________ __________________ Department Chair Date ______________________________________________ __________________ Dean of the School of Health Sciences Date Evidence-Based Fever Management Teaching Intervention for Emergency Room Nurses Fever has long been a common childhood illness faced by parents, physicians, and nurses. In fact, 30 percent of visits to the emergency room included fever as the main complaint (Watts, Robertson, & Thomas, 2003). Over the decades the research has shown fever to be an adaptive physiological mechanism and shown to improve survival rates and shorten the duration of the disease...
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...Skills Validation PNCI Eliana Ruiz Age: 86 Weight: 55 kg Base: Standard Adult Overview Synopsis The learner will be providing care to an 86-year-old Hispanic female admitted to the MedicalSurgical Unit with a non-healing wound on her right upper leg where a femoral-popliteal bypass graft was performed two weeks ago. She is diabetic and injured her left ankle by tripping on a curb on the way to the hospital. She is anxious about not being able to care for herself when she returns home. She lives alone but has a daughter close by, and has no insurance. This Simulated Clinical Experience™ (SCE™) has five states, that are transitioined manually. With manual transitions, the instructor should advance to the applicable state when appropriate interventions are performed. Initially, in State 1 0900 Hours Assessment, the learner is presented with a patient who is febrile and exhibiting other signs of infection. Initial assessment reveals a temperature of 38.6o Celsius, HR in the 80s, BP in the 140s/80s, RR in the low 20s and SpO2 in the mid 90s on room air. Breath sounds demonstrate crackles bilaterally. The patient is anxious and incontinent of urine. She has a non-productive cough and reports tenderness over the left ankle. Initial treatment includes application of an elastic bandage to the left ankle, assessment of pain level, administration of pain medications, insertion of a urinary catheter and a sterile wet-to-moist dressing change to the graft site. If learners request...
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...0 3 0 Electronic Health Records in the Physician Office CHAPTER OUTLINE Patient Flow in the Physician Practice Step 1. Pre-Visit: Appointment Scheduling and Information Collection Step 2. Patient Check-in and Payment Collection Step 3. Rooming and Measuring Vital Signs Patient Examination and Documentation Step 4. Patient Checkout Step 5. Post-Visit: Coding and Billing Post-Visit: Reviewing Test Results Coding and Reimbursement in Electronic Health Records Computer-Assisted Coding Clinical Tools in the Electronic Health Record Decision-Support Tools Tracking and Monitoring Patient Care Screening for Illness or Disease Identifying at-Risk Patients Managing Patients with Chronic Diseases Improving the Quality and Safety of Patient Care with Evidence-Based Guidelines E-Prescribing and Electronic Health Records Keeping Current with Electronic Drug Databases Increasing Prescription Safety Saving Time and Money LEARNING OUTCOMES After completing this chapter, you will be able to define key terms and: 1. 2. 3. 4. 5. 6. 7. 8. 9. List the five steps of the office visit workflow in a physician office. Discuss the advantages of pre-visit scheduling and information collection for patients and office staff. Describe the process of electronic check-in. Explain how electronic health records make documenting patient exams more efficient. Explain what occurs during patient checkout. Explain what two events take place during the post-visit step of the visit workflow. Describe the advantages of computer-assisted...
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...0 3 0 Electronic Health Records in the Physician Office CHAPTER OUTLINE Patient Flow in the Physician Practice Step 1. Pre-Visit: Appointment Scheduling and Information Collection Step 2. Patient Check-in and Payment Collection Step 3. Rooming and Measuring Vital Signs Patient Examination and Documentation Step 4. Patient Checkout Step 5. Post-Visit: Coding and Billing Post-Visit: Reviewing Test Results Coding and Reimbursement in Electronic Health Records Computer-Assisted Coding Clinical Tools in the Electronic Health Record Decision-Support Tools Tracking and Monitoring Patient Care Screening for Illness or Disease Identifying at-Risk Patients Managing Patients with Chronic Diseases Improving the Quality and Safety of Patient Care with Evidence-Based Guidelines E-Prescribing and Electronic Health Records Keeping Current with Electronic Drug Databases Increasing Prescription Safety Saving Time and Money LEARNING OUTCOMES After completing this chapter, you will be able to define key terms and: 1. 2. 3. 4. 5. 6. 7. 8. 9. List the five steps of the office visit workflow in a physician office. Discuss the advantages of pre-visit scheduling and information collection for patients and office staff. Describe the process of electronic check-in. Explain how electronic health records make documenting patient exams more efficient. Explain what occurs during patient checkout. Explain what two events take place during the post-visit step of the...
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...Where There Is No Doctor 2010 Where There Is No Doctor 2010 Library of Congress Cataloging-in-Publication Data The Library of Congress has already cataloged the 10-digit ISBN as follows: Werner, David, 1934Where there is no doctor: a village health care handbook / by David Werner; with Carol Thuman and Jane Maxwell-Rev. ed. Includes Index. ISBN 0-942364-15-5 1. Medicine, Popular. 2. Rural health. I. Thuman, Carol, 1959-. II. Maxwell, Jane, 1941-. III Title. [DNLM: 1. Community Health Aides-handbooks. 2. Medicine-popular works. 3. Rural Health-handbooks. WA 39 W492W] RC81.W4813 1992 610-dc20 DNLM/DLC for Library of Congress 92-1539 CIP Published by: Hesperian 1919 Addison St., #304 Berkeley, California 94704 • USA hesperian@hesperian.org • www.hesperian.org Copyright © 1977, 1992, 2010 by the Hesperian Foundation First English edition: October 1977 Revised English edition: May 1992 Eleventh printing: July 2010 ISBN: 978-0-942364-15-6 The original English version of this book was produced in 1977 as a revised translation of the Spanish edition, Donde no hay doctor. Hesperian encourages others to copy, reproduce, or adapt to meet local needs, any or all parts of this book, including the illustrations, provided the parts reproduced are distributed free or at cost—not for profit. Any organization or person who wishes to copy, reproduce, or adapt any or all parts of this book for commercial purposes, must first obtain permission to do so from Hesperian. Please contact Hesperian before...
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...Pain Assessment and Management G u i d e l i n e f o r Marlene Walden, PhD RNC NNP CCNS Sharyn Gibbins, PhD RN NNP P r a c t i c e , 2 n d E d i t i o n Pain Assessment and Management Guideline for Practice, 2nd Edition This guideline is an outline of the pain assessment and management practices that currently are accepted and documented by experts in the field of neonatal care. In addition, it summarizes and recommends pain assessment and management practices based on the best evidence for the nursing care of infants. This guideline does not preclude the use of manufacturers’ recommendations or other acceptable methods of assessing and managing pain in infants. The use of other practices known to improve the quality of neonatal care is encouraged and not restricted by this document. The National Association of Neonatal Nurses (NANN) developed this guideline in response to members’ requests. Broad in scope, it can provide a foundation for specific nursing protocols, policies, and procedures developed by individual institutions. Authors Marlene Walden, PhD RNC NNP CCNS Sharyn Gibbins, PhD RN NNP Reviewers Daniel Batton, MD, American Academy of Pediatrics Sandra Sundquist Beauman, MSN RNC Jim Couto, MA, American Academy of Pediatrics Mary Ann Gibbons, BSN RN Melinda Porter, RNC CNS NNP Ann Stark, MD FAAP, Chair of AAP Committee on Fetus and Newborn Carol Wallman, RNC NNP MS, NANN/AWHONN Liaison to AAP Committee on Fetus and...
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...Essential Components of Documentation for Paraprofessionals OBJECTIVES At the completion of this training, participants will – Understand the importance of documentation – Know how to set up and maintain records – Understand the connection between accurate record keeping and the Individualized Treatment Planning process – Understand what information needs to be in progress notes – Learn how to accurately set up and maintain a medication administration record – Understand that records are confidential – Know how to conduct a quantitative review of a record – Know how to conduct a qualitative review of a record – Be able to track consumer issues through a record revised 8.08 The challenge for all service providers is to understand the “whys” of documentation while also understanding the “hows”. If we are able to understand the “whys”, the mundane tasks of everyday documentation and record keeping become something that is part of the whole instead of the dreaded work we face every day. revised 8.08 Let’s Begin With A Little Chat about Program Quality You may notice that this training seems to be mostly about paper, not people. That doesn’t mean we don’t like people In fact some of our best friends are…. well, people. revised 8.08 And it’s not that we think “Good Paper Equates to Good Program” In fact, we’ve seen some very lousy programs that have really “good paper”. We call that, “doing the wrong thing, very, very well”. revised 8.08 But...
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...NURSING PROCESS PAPER Student Name: Date of Care: 10/14/09 Date of Admission: 10/10/09 I. HEALTH STATUS | Admitting Dx: COPD Exac/Chest Pain | Pt. Init.D.R | Rm No.353 | Age60 | SexM | RaceCaucasion | ReligionCatholic | OccupationDisabled | Surgery: Medical Treatment: Back Surgery/ Coronary Artery Bypass Grafting COPD Exac/Chest Pain | Chief Complaint/Reason for Hospitalization & Hx. of Present Illness (with 1-8 critical characteristics, Jarvis pg. 85) Chest Pain | | 1.Location: Midsternal chest pain radiating to left arm. 2. Quality/characteristics: Squeezing, tightening, felt like chest was going to explode. 3. Quantity: 8 on a scale from 1-10 4. Setting: at rest 5. Associative factors: SOB and nausea 6. Aggravating/relieving factors: Aggravated by activity, unable to relieve in any position 7. Timing (Onset, duration, frequency): Sudden and constant pain 8. Patient perception: Thought he was having a heart attack. | Other illness or conditions & year of onset. | | AllergiesNKA | COPD- 2004 Deep Vein Thrombosis -2002Anxiety-2000Depression-1998Lumbar/Cervical Spondylosis-1982HTN- 19XX-Patient cannot recall exact year | | Immediate Teaching Needs | | Hospital safety- Reminded patient to call for assistance, call light within reach, non skid footwear for reduction of falls. Talked with patient regarding fall safety. Teach non-pharmachological...
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...NURSES: PARTNERS IN ASTHMA CARE NIH P UBLICATION N O . 95-3308 OCTOBER 1995 N ATIONAL I NSTITUTES OF H EALTH National Heart, Lung, and Blood Institute i T ABLE OF C ONTENTS PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NURSES’ ASTHMA EDUCATION WORKING GROUP . . . . . . 1. PATHOPHYSIOLOGY OF ASTHMA . . . . . . . . . . . . . . . . . 2. PRACTICAL GUIDE TO ASTHMA MANAGEMENT . . . . . . GOALS OF ASTHMA MANAGEMENT . . . . . . . . . . . . . . . GENERAL PRINCIPLES OF ASTHMA MANAGEMENT . . . FOUR COMPONENTS OF ASTHMA MANAGEMENT . . . . Asthma Management Component 1: Objective Measures of Lung Function . . . . . . . . . . . . Spirometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Peak Flow Monitoring . . . . . . . . . . . . . . . . . . . . . . Actions/Implications for Nurses: Objective Measures . . . . . . . . . . . . . . . . . . . . . . . . . Asthma Management Component 2: Environmental Control Measures. . . . . . . . . . . . . . . . Allergens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Irritants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Actions/Implications for Nurses: Environmental Control . . . . . . . . . . . . . . . . . . . . . . Asthma Management Component 3: Pharmacologic Therapy . . . . . . . . . . . . . . . . . . . . . . . Two Major Groups of Asthma Medications: Anti-inflammatory and Bronchodilator . . . . . . . . Step-Care for Chronic Asthma...
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...Nursing Practice: Acute NURS7113 Nursing Practice: Acute NURS7113 Due Date: 2nd May 2016 by 0900hours Due Date: 2nd May 2016 by 0900hours Paper Coordinator: Paper Coordinator: | Faculty of HealthAssignment Cover Sheet | Please complete this sheet and attach to your assignment, ensuring that you print clearly. Student ID: | 21303376 | | | Student Name: | KrishnitaSen | | | Programme Name: | Bachelor of Nursing (Pacific) - Year 3 | | | Paper Name: | NURS7113: Nursing Practice- Acute | | | Assignment Name: | Summative Case Study and Reflection | | | Tutor Name: | | | | Date Submitted: | 2nd May, 2016 | | By submitting this assignment, I certify that the work presented follows the guidelines set out in the Programme Handbook and is my own original work. We reserve the right to withhold marks or request further information if we are not satisfied that the work presented is the student’s own, or has been referenced appropriately. Introduction A nurse has a crucial responsibility to make accurate and appropriate clinical decisions in an acute setting working in partnership with health consumers across varies lifespan (Crisp, Taylor, Douglas, Rebeiro, 2013). The assignment aims to help develop the clinical skills of a nurse by demonstrating key aspects of client-centered nursing care in an acute setting during the placement. This assignment is based on a health consumer; that was encountered during clinical placement who is of...
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