1 Assess the patient’s clinical need for blood and when it is required. 2 Inform the patient and/or relatives about the proposed transfusion treatment and record in the patient’s notes that you have done so. 3 Record the indications for transfusion in the patient’s notes. 4 Select the blood product and quantity required.…
I am so glad to have you in the clinic! Thanks for the work you have done the past 4 weeks! Now, it is your turn to take the reins! Finally chances to put into place all of those wonderful things you learned in college! Much to your surprise, your first morning on your own and you walk into the following situation: 1.…
TACT consulted with Dr. Snyder it was recommended to refer for inpatient hospitalization for safety and stabilization. TACT assisted the ED doctor in completing IVC paperwork. TACT will search for appropriate…
Upon receipt of this referral, I research and contacted Beaumont Oakwood Hospital in Dearborn, MI to discuss the case with the assigned case manager. I spoke with the operator who replied, Mr. Heinz was on 3 north room 380-2. I asked for the floor nurse’s station number and I was informed they couldn’t give the number out, but she would transfer me. I was transferred and spoke with the nurse Karen who informed me that they won’t be able to provide me with any information.…
Telephone contact made to the patient. Two patient verifier used to confirm name and DOB. Per Dr Brinkley, requested made for patient to bring in his GI summary for his polyps removal in April. Informed the patient that this information needs to filed into his military records. Also his provider would like to review the summary.…
Spoke with the patient about her discharge summary from Hartford Hospital stating there's no record. In addition, this writer addressed with the patient about her shouting at this writer to remove the hold, at which this writer explained to the patient, she was placed on hold to address this issues as she was asked by Nursing on more than one occasion. The patient apologized for her behavior as this writer expressed her demeanor was inappropriate. The patient stated that she may have a copy of the discharge summary in her car. This writer followed the patient to the lobby area as she head towards her car and then handed this writer Hartford discharge summary as the patient was seen to address her Lymphadenitis.…
Review of the medical record indicates that she was recently admitted to MHS for complaints of increasing fatigue, lethargy and leakage from her indwelling foley catheter. She had a urology consulted with Dr. Beltran for evaluation of chronic indwelling urinary catheter and persistent leakage with recurrent UTI. Review of her medical history indicates multiple sclerosis, UTI, Memory loss, Pressure ulcer, facial neuralgia, blood transfusion, chronic kidney disease, decubitus ulcer of back, GERD (gastroesophageal reflux disease), hypertension and legally blind. At today’s visit she is accompanied by her husband.…
Notified by the MOP. Two patient verifer used to confirm name and DOB. The MOP states at the end of Sept her son was seen by Major Blount and optometry and was diagnosis with uveitis in his right eye. MOP state she believes her son has uveitis in the left eye. She states that her son states that he has blurr vision in the left eye, 2/10 pain, with burning and itching.…
The patient is of the Hispanic background. 1. This patient is at risk for infection or developing sepsis due to being 10 days postop for an amputation. Complete blood count measure how many white blood cells are circulating in the bloodstream.…
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Introduction “As defined by The American Nurses Association (ANA), delegation is the transfer of responsibility for the performance of a task from one individual to another while retaining accountability for the outcome” (Kelly, 2012 p. 369) Delegation occurs when a task is assigned based on job description and matching the staff to patient needs (NCSBN, 2005). Decisions on delegation are based on principles according to the individual’s scope of practice. Before any task is delegated, it is important to ensure the education, skill, knowledge, and judgment levels of the personal being assigned the task. The RN is accountable for assessing, diagnosing, implementing, and evaluating the patient’s plan of care (NCSBN, 2005). Nurses are legally…
Faced with cancer in my mid 30’s, I became an instant active health care consumer. I am proud that I never sat back and let the many doctors lead the way with my care. I requested copies of all my tests and researched everything. I went to appointments armed with questions. with the type of cancer I had, I was at high risk for ovarian cancer.…
I need to perform an assessment on the patient, including vital signs. I also look at labs and testing that was completed. I need to contact the physician with any abnormal vitals, labs, or testing. Recommendations are based on my assessment of the…
Reflection To protect the identity of my patient who I met with during my placement, I named her as Mrs Sawyer. This is due to confidentiality (NMBA, 2008b). When I arrived at the ward at 7:00 am, the registered nurse gave us her handover report about Mrs Sawyer condition. I learnt that Mrs Sawyer was admitted to the orthopaedic ward with a right neck of femur and right now she is recovering after surgery. I’ve also learned that Mrs Sawyer was unsettled and complained of pain during the night.…
The level of supervision that is required in any given situation is dependent upon the complexity of the patient’s condition. Because of the changing nature of these complex situations, an RN should be immediately available to assess the patient and to co-ordinate direct and inspect the practice provided by the…