When starting off the day I did use the 60 second assessment tool to ensure there were no abnormalities with my patient. I looked for any IVs the patient many of had, there was one but no fluids were attached. I also looked for urine output from the patient because the patient did have a catheter in place. I also checked to ensure safety precautions were in place because the patient was a fall risk, the reason why he was here in the first place. I think this tool can for sure help to pick out the priorities of your patient with just a quick glimpse.
All of my patients outcomes were met today. He ate the majority of his breakfast, which was being monitored. He also took all of his medications, nasal sprays, and inhaler. The Patient was determined fit to go home and was to be discharged today. So I removed the patients IV, and helped secure his ankle bag for him before he was to start getting ready to pack up for home.
Receiving the news that the patient was able to go home today endured that the patients outcomes were met. He also received the type of leg bag he preferred (ankle bag) for his catheter since he was to go home with it. He was briefed on his discharge information given a list of the medication he was to take including a new antibiotic for his UTI, and a referral to urology
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It involves being confident in what you know and speaking up when needed. I think as a novice nurse it is sometimes hard to be as vigilant assertive as we would want to be because being so new sometimes us new nurses don't always have to self confidence that we should. For example questioning a doctors order or medications he has prescribed and noticing that something is off would be a situation where one would need to be assertive and question actions. I think being vigilantly assertive is a skill that will come more of a second nature the more confident and experience one becomes as a
Pre-operatively patients were brought into the only pre-op room where forms and consent were looked over, allergies verified, proper surgical site confirmed by staff and patient, last minute medication given (antibiotic) and last minute concerns answered.
This is my sixth clinical shift with my preceptor at Saunders Medical Center in Wahoo, NE, and it was on May 11, 2018 (Friday). Today, I had the chance to work in the OR, following nurse Mikayla. My duties for the day were to practice my IV skills on all surgical patients (15 of them) and check them all into their preoperative rooms. The patient census that I cared for includes: W. K. a 67-year-old male scheduled for a colonoscopy; A. J. a 77-year-old female scheduled for a colonoscopy; L. P. a 74-year-old female scheduled for a colonoscopy; D. F. a 53-year-old male scheduled for a colonoscopy; C. L. a 52-year-old male scheduled for a colonoscopy; K. M. a 21-year-old female scheduled for an
The purpose of this clinical journal entry is to elaborate on the details of lab day three. On lab day three, we had check-off for blood pressure and apical pulse. In addition, we took a safety test, and learned about mobility, immobility, how to use ambulatory devices, and reposition (C#4, C#6).
It was a quiet and pleasant Saturday afternoon when I was doing my rotation at the surgical medical unit at Holy Cross Hospital. It’s time to get blood sugar levels from MM, a COPD patient. His BiPAP was scheduled to be removed before his discharge tomorrow. When I was checking the ID badge and gave brief explanation what I needed to do. The patient was relaxed, oriented and her monitor showed his SPO2 was 91, respiratory rate was 20. His grandchildren knocked the door and came in for a visit. I expected a good family time, however, the patient started constant breath-holding coughing and his SPO2 dropped to 76 quickly. With a pounding chest, the patient lost the consciousness. His grandchildren were scared and screaming,
Tabitha walked onto the medical-surgical unit and received report on five patients in a record ten minutes before she began her busy shift Tuesday morning. The off going nurse managed to talk about the pet peeves and subjectives of each patient but was in a rush to make it to the monthly nursing practice council meeting and ‘everyone is doing fine’. Tabitha was unaware of the potential chaos that would ensue as her day progressed. As Tabitha walked into her patients’ rooms that morning to introduce herself, little did she know that Mrs. Jones is a high fall risk with no signage or alarms plugged in; Mr. Hill has fluids infusing at one hundred and fifty milliliters per hour with a history of congestive heart failure (CHF); and another patient is scheduled for surgery with no pre-operative paperwork or consents completed.
On Wednesday, April 18th, I attended my Acute Care evening clinical at Hays Medical Center. At the beginning of the clinical, Professor Keil assigned us to a nurse and patients. I followed a nurse with 5 patients. We then went down to the floor to wait for report. My nurse, Brittany, and I received report on all five patients from the day shift nurses. After receiving report, we went through patient’s medications and wrote down the medications that we would be passing that evening and at what time. After receiving report and writing down medications, we began.
Over the last review period General Hospital has had a number of compliance achievements including, for the incident reports there were minimal number of incidents reactions to blood transfusion, as for the operative reports they had many of them dictated in a timely manner, the health & physical reports were also dictated in a timely manner at a rate of approximately 74% compliance, as for the physician orders Dr. Jones had a turnaround rate in the positive manner 2/3 of the time, the release of information is at a 60% rate. In the Core Measure
On admission to a healthcare facility, a health assessment is a mandatory tool in assessing the patient’s health status. In general an assessment is broken down in a two types of reviews, by conducting a health history which includes the collection of subjective data (information elicited by the patient or patients family members) and a physical examination of the patient which includes the gathering of evidence based data (Wilson & Giddens, 2009). Collecting and documenting accurate information is imperative in providing the allied health team this information to facilitate an efficient and well-formed care plan, as well establishing a baseline for subsequent assessments (Springhouse, 2004; Wilson & Giddens, 2009).
Overall today was extremely busy. There was a total of 21 patients seeking therapy. For each patient that was seen throughout the day, I prepared hot packs and ice packs and monitored them throughout each exercise session. Aside from supervising patients, I was able to start my Needs assessment with patients. I selected 8 patients based on their age and frequency of visit, in order to gather accurate and efficient information overtime. I was able to interview patients during their 8 minutes hot pack session, and then I introduced myself and stated the purpose of this study/intervention. Each patient was very engaged and responded to each question appropriately. I did not hand out brochures on this day because I felt it would be beneficial to
On my first day of week three clinical at 0830, client W and I were on our way to the dinning room and client B asked me to put his jacket on, so I told client W that I would meet him in the dinning room. After I helped Client B, I was on my way to the dinning room and nurse A told me that client W was experiencing difficulty breathing and we needed to give him his 0900 inhalers earlier. He was having audible wheezing and rapid respiratory rate. Therefore, we had to give client W his inhalers, SalbutaMOL Sulfate, which is a bronchodilator to allow the alveoli in the lung to open so th...
In November, 2013, I spent the Thanksgiving week at the urgent care on a daily basis due to an abscess. Finally, VMC staff admitted me on the
She told me that this particular client’s doctor was most likely going to be coming in and order that her catheter be removed and take her off the normal saline 0.9%. She said that she should be starting to get up and moving today. After I had introduced myself to my client and took her vitals I talked to her about her daily goals and what I would be doing today with my assessments. When I came back to my patient to do my head to toe assessment, I asked if she would like to move to the chair when we were done, she said she would try but she it was very painful to sit up because that put pressure on her incision line. I asked if she would like her pain medication that she didn’t want earlier, because I discussed that by the time I finished with my
Looking back the simulation lab, I realize that I have so much to learn about myself as I played the role of the primary nurse in the total knee replacement scenario. In the situation, my colleague and I found out that our patient, Kari Bradshaw, was bleeding. My first thought is to grab an ice pack and didn 't recognize that I need to put pressure on the dressing. After my partner checked the vitals, I decided to call the technician to get the lab results. I reported the diminished hemoglobin count to the physician only to realize that I did not have the vital signs values. I received an order for saline bolus during the phone call. I also put the patient in two liters of oxygen in nasal prongs but the oxygen saturation was not improving so I turn it up to four liters. At that moment, my patient passed out. My colleague called the doctor and got an order for oxygen via non-rebreather mask to the patient and infuses two units of packed red blood. She also asked us to prepare the patient for the operating room. I asked the other nurse for vital sign assessments
Although my day was challenging as well as tiring at times, the personal-satisfaction I received from delivering patient centered care made it more than worthwhile. Increasing my patient’s comfort, by removing her NG-tube and mitts, can easily be identified as the highlight of my
Prepared ahead of time, patient’s are taught what to expect from report and know they will have an opportunity to present any concerns they have after pertinent information has been addressed (Evans et al., 2012). In addition to making introductions, time spent in the patients room can be an occasion to also visually check for safety, verify intravenous administration rates and review the plan of care over the next few hours. Making these introductions, and reviewing the plan of care, eases the anxieties of patients that may occur during the period of standard report in which staff not visible (Evans et al.,