...National Patient Safety Goals On Reduce Your Risk of Falling Joanna Dela Pena NR224 Chamberlain College of Nursing Introduction Falls are a public health problem worldwide. Hospitalization increases fall risk because of the unfamiliar environment, illnesses, and treatments. Patient falls and fall-related injuries are devastating to patients, clinicians, and the health care system. A single fall may result in a fear of falling and different complications that will reduced mobility, leading to loss of function and greater risk of falls. Older adults are more likely to be injured from a fall. Injurious falls also increase hospital costs and lengths of stay (Bates DW, Aug 1995). Factors affecting fall especially in older adults like environment or health care setting, are rising their numbers simply because of inconvenient structures of facility. Older patient that needs to wake up at night struggling to find their call light for help would literally just go to the bathroom by themselves. Without their full cognitive thinking ability to turn on any light and not able to hold their urine because of many reasons like incontinence, would result to fall accidents. People of any age can also be risk from fall injuries due to many psychological and physiological changes they are into. Changing medications for example could make a person dizzy because the body has not adjusted yet to the change. That person could not be aware of the adverse effect and still would do his/her normal...
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...classification of coding use | Admission SummarySheet | 2. CM | Clinical Modification | Classification of coding use | Admission Summary Sheet | 3. N/A | Not Available | This information concerning the patient is not available | Admission Summary Sheet | 4. ER | Emergency Room | States where the patient was taken for medical care | History & Physical | 5. C/O | Complains of | She made complain of | History & Physical | 6. SOB | Shortness of breath | Symptoms she was having | History & Physical | 7. mg | Milligram | The dosage of medication used | History & Physical | 8. po | By mouth | Method the patient will take her meds | History & Physical | 9. tid | Three times a day | The amount of times the patient will take her medication a day | History & Physical | 10. qd | Everyday | The frequency the patient needs to take her medication | History & Physical | 11. qod | Every other day | Skip a day then take another dose | History & Physical | 12. qhs | Every day at hours of sleep | A specific time the patient needs to use her medication | History & Physical | 13. tabs...
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...providers shall: History & Physical 1. A complete history and physical examination shall, in all cases be done no more than 7 days before or 24 hours after the admission of a patient. Physical examinations may be used from the previous hospitalization if the examination was within 30 days. A physical examination may be accepted from a physician’s office if the examination was within 30 days and meets the standards as defined by hospital policy and procedure. If the patient was transferred from another hospital, the physical examination may be accepted if the examination was done within 30 days, provided they are updated within 24 hours of admission or registration by the attending physician. In the above three cases, the attending physician must validate the examination in the medical record (on the physical exam) by noting that there are no significant findings or changes and signs and dates the report. Guidelines for contents of a complete History & Physical include: a. The Emergency Room documentation form may not be used as a History and Physical. b. A complete history and physical examination shall be recorded before the time stated for operation or the operation shall be canceled unless the attending surgeon indicates it is an emergency procedure. c. If the complete history and physical was dictated shortly before the operation, but not yet transcribed, the surgeon/physician will document that the history and physical has been dictated. A short History & Physical...
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...REQUIRED UNIFORM ASSIGNMENT GUIDELINES THE HEALTH HISTORY AND PHYSICAL EXAMINATION PURPOSE As you learned in NR302, before any nursing plan of care or intervention can be implemented or evaluated, the nurse conducts an assessment, collecting subjective and objective data from an individual. The data collected are used to determine areas of need or problems to be addressed by the nursing care plan. This assignment will focus on collecting both subjective and objective data, synthesizing the data, and identifying health and wellness priorities for the person. The purpose of the assignment is twofold. • To recognize the interrelationships of subjective data (physiological, psychosocial, cultural and spiritual values, and developmental) and objective data (physical examination findings) in planning and implementing nursing care • To reflect on the interactive process that takes place between the nurse and an individual while conducting a health assessment and a physical examination COURSE OUTCOMES CO 2: Utilize prior knowledge of theories and principles of nursing and related disciplines to integrate clinical judgment in professional decision-making and implementation of nursing process while obtaining a physical assessment. (POs 4 and 8) CO 3: Recognize the influence that developmental stages have on physical, psychosocial, cultural, and spiritual functioning. (PO 1) CO 4: Utilize effective communication when performing a health assessment. (PO 3) CO 6: Identify...
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...Focussed Assessment In the given case study patient has persistence vomiting for eight days and she took Antaacids to relieve the symptoms. She is dehydrated, and her lab results shows she has metabolic alkalosis. In focused assessment, detailed nursing assessment of particular body system(s) connected to the current problem is required. One or more body system may be involved.Nausea and vomiting can ocurr due to different reasons like food poisoning,chloecystitis or intestinal obstruction..For the patient with vomitting,intially the health care provider need to pay attention to signs of dehydration. Like assessing monitoring blood pressure and observing for hypotension, skin turgour and mucous membranes changes (McCance, Huether, Brashers, & Neal, 2014). General Assessment: Patient had dark circles under the eyes. She looked worn out. She was feeling anxious. Her energy level was very low. She was speaking very slowly. Abdominal Examination: Abdomen is soft to touch. Patient has some epigastric pain. Bowel sounds are decreased.No bloating or acidity. Signs of hypo-motility may indicate an increased risk for nausea and vomiting. Cardiovascular system: Patient is hypotensive with tachycardia. No heart regurgitation or murmur. Heart rhytm is regular. Patient is feeling tired and dizzy. Pulmonary system: Patient is in metabolic alkalosis. Respirations rate is low 12 breaths per minute. Patient is taking deep regular breaths. Lungs are clear to ausculation...
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...1 NRSG125 HEALTH ASSESSMENT 1. Introduction to physical assessment techniques LEARNING OUTCOMES: At the successful completion of this session students will be able to: * Demonstrate the techniques of inspection, palpation, percussion and auscultation at a beginning level * Discriminate between intensity, duration, pitch and quality of percussion sounds at a beginning level * Differentiate between light and deep palpation * Identify the components of a stethoscope. * Identify and describe the use of a variety of equipment used for health assessment * Establish an environment suitable for conducting a physical assessment. * Describe safety precautions and legal considerations when performing a physical assessment. PRE-LAB READING: Prior to attending this lab students should read the following: * Estes, M, E, Z., Cajella,P.,Thoebald, K.,Harvey, T., (2013). Health assessment and physical examination (1st ed.) South Melbourne, Vic., Australia; Cengage Learning. pp 81-96. * Tollefson, J. (2012) Clinical psychomotor skills (5th ed.) South Melbourne, Vic. Australia.: Cengage Learning. pp 23-28 List the physical assessment techniques in the correct order, and provide two examples of findings. Assessment | Description | Example of findings | technique | | | | | | Inspection | Examination conducted by looking at the body parts being examined, through observation, focus images,...
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...potential hires. The following suggestions will help you get started: • Sometimes it is easier to start at the end. Think of the diagnosis the patient will receive. If you know what the end diagnosis will be, it makes it easy to know what symptoms, signs, and diagnostic methods would be used to achieve that diagnosis. • For the History of Present Illness, consider what questions the physician might ask the patient about his or her chief complaint and symptoms and then chart that in this section. This section serves as an account of what the patient would report, based on their symptoms. Remember, symptoms are subjective, in that they are conditions experienced by the patient, and are therefore included in the patient history. • For Past Medical History, document anything the patient may indicate in terms of past medical conditions that would be relevant to his or her current illness. • For the Physical Exam section, document the observable signs. Signs are objective, in that they are measurable conditions, and therefore included in the physical exam. This includes vital signs or anything observed by performing the patient physical exam. • For the Diagnostic/Lab Results, include the testing or procedures required to prove this diagnosis. • For...
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...History of child abuse BSHS/408 February 15 2016 Chiffone N Shelton Abstract In order to discuss child abuse and neglect it is important to have a clear understanding of what child abuse and neglect is and the different form of child abuse. How the various types of child abuse and neglect are different from one another, ill-treatment of children comes in many forms, physical abuse, sexual abuse, emotional ill-treatment, and child neglect. Child neglect comes in many forms and occurs when a child is not given the care, supervision, affection, and support that they need; neglect can occur through physical neglect, emotional neglect, medical neglect, and education neglect. What are the implications of child abuse and neglect, For fiscal year 2011, States reported that 676,569 children were victims of child abuse or neglect While physical injuries may or may not be immediately visible, abuse and neglect can have consequences for children, families, and society that last lifetimes, if not generations . History of child abuse In this essay, I will be discussing the history and implications of child abuse and neglect. I will explain how the history of child abuse and neglect helped shape current policies and what the extent of child abuse and neglect is. I will address how various types of child abuse and neglect are different and how these types are viewed from different theoretical perspectives; I will also explain what the implications of child abuse and neglect are...
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...717/17 I met Mr. Morgan at the office of Dr. Kohn. Mr. Morgan arrived alone. He is willing to provide prior and current medical history and work with a nurse case manager. MEDICAL FACTORS Mr. Morgan reports that while working he was throwing a tailgate into the dumpster the left arm was hit in the bicep when it bounced back. He had immediate deformity to the arm. He was seen at an urgent care clinic and sent to orthopedic Dr. Kohn for repair of a torn bicep tendon. The...
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...patients with dissociative issues have a history of adolescence physical or sexual abuse. The study portrayed in this paper was intended to figure out the commonness of dissociative side effects in the populace and to duplicate past studies which inferred that a history of physical and sexual abuse is discovered ordinarily around individuals who are hospitalized for mental or psychiatric issues. The subjects comprised of 98 inpatients (counting just the individuals who finished the study) spanning in age from 18-60 years who were "consecutively admitted to all units of a psychiatric teaching hospital, excluding admissions to the chemical dependency unit" (Chu & Dill, 1990, p. 887). Patients completed three self-report instruments. The Dissociative Experiences Scale (DES) was used to measure dissociative symptoms. The Symptom Check List- 90- R was used to assess general psychiatric symptoms. The Life Experiences Questionnaire (LEQ), which makes inquiries about youth trauma, was used to assess the extent of adolescent physical and sexual abuse. Diagnoses, presenting symptoms, and treatment history information were likewise acquired for each subject. A relationship was then directed to search for relationships between history of misuse and levels of separation. This study, hence joins together components of mental testing, review, case history techniques, and utilization connections. Fifty-one percent of the subjects had endured physical abuse. Thirty-six percent of the subjects...
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...abscess that formed from the initial surgery and had a central line inserted for long-term antibiotics. She is scheduled to go home with home health overseeing her antibiotic therapy. This tracer patient has shown that there are areas of our patient care that we need to improve upon in order to be in compliance with the Joint Commission standards. According to The Joint Commission (2014) compliance with standard PC.01.02.03 requires that a history and physical examination be done within 24 hours of inpatient admission and prior to surgery. In the case of this tracer patient, the history and physical was completed more than 72 hours after admission. Further, this patient underwent surgery two days after admission, prior to the completion of a history and physical exam. The history and physical examination is a very important tool in a patient's care. It provides information regarding the patient's overall condition as well as potential risk factors that may affect the planned course of treatment. The history and physical allows the treatment team to determine if any additional interventions are required to reduce risk to the patient. The fact that this fundamental aspect was delinquent in this patient's care is unacceptable and a corrective...
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...History of the Olympics It is very hard to try and see anything negative about the history of the Olympics. I personally have not seen the negative things in it. I really tried my hardest in to trying to find something that might be able to help with the negative part of the history of Olympics but I couldn’t find anything. Especially towards teaching I honestly read and researched nothing but positive things when it came to the Olympic history and my profession. So unfortunately I will only be writing about why the history of the Olympics is positive and beneficial to teaching physical education. The history of the Olympics has helped me realize just how important it is towards physical education. Of course now of days I think that people just watch for mere entertainment. But when the Olympics first began in 1796 a lot of people didn’t now a lot about it. As it got around the event began to evolve more and more. The Olympics really helped bring a lot of people and things together. It allowed for people all over the world to be able to not only show case there talent to the world but it was also a gate opener to new sports. As the Olympics evolved a lot of different sports began to evolve also. Which is great for my profession because it gave my profession a breath of fresh air? It allowed physical education teachers a chance to talk about different sports and for students to play, learn and experience different things. The games and...
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...for a patient. The ability to locate vital patient healthcare information is crucial to the assessment of patient care. A patient’s record can be comprised of five main parts consisting of medical history, lab results/diagnostic results, problem list, clinical notes, and treatment notes. The medical history includes patient demographics, chief complaint (reason why patient is seeking care), history of present illness, past medical history, family history, social history, allergies, medications, review of systems and physical exam information. Patient demographics information consist of name, birth date, address, phone number, gender, race, marital status, attending physician, insurance information, pharmacy name, pharmacy phone number and religious preference. Chief complaints consist of the reason(s) why the patient is seeking care. History of present illness list the history of the current illness beyond that of the chief complaint and listed in chronological order. Past medical history list the past and current medication conditions and includes past surgical history. Family history includes descriptions of age, living status (dead or alive), and presence or absence of chronic medical conditions in immediate family members (parents, siblings and children). Social history documents a patient’s lifestyle and characteristics. This also includes the use of alcohol, tobacco, drugs and documents, type, amount and frequency. This is also where patient’s dietary habits...
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...There are many similarities between a RN and an APRN physical examination, yet there are differences as well. Both a RN and an APRN are conducting physical exam to determine and differentiate normal from abnormal findings. Both will used a general survey to gather patient history and perform head to toe physical exam. Both might gather information on family history, smoking history, nutrition history, and so forth. In addition, they will perform complete head to toe assessment of the body systems. In an acute care setting, I believe that a RN spend more time on initial assessment during admission and on subsequent days the assessment is not thorough. In addition, the RN are entitled to check vital signs in acute setting or an LPN checks vital...
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...collect from Ashley and her mother? • History of present illness Dental pain, mouth lesions: Ashley doesn’t have dental pain, but she has lesion in the mouth, especially in the larynx. She is suffering from pain in the throat. It means, she might have laryngitis. Dentures or dental appliances: Ashley doesn’t have dentures or dental appliances. Medications / herbal supplements: She doesn’t have medications / herbal supplement. She doesn’t use any medications and herbal supplements. Pain with swallowing: She has pain with...
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