References: Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. M. (2011). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (Eighth Edition). St. Louis, MO: Elsevier Mosby.…
UP.01.01.01 requires the organization to conduct a pre-procedure verification process prior to the start of any procedure. The hospital meets this standard by following its policy titled “Site Identification and Verification (Universal Protocol)” which describes the process that is used prior to the start of any operative or invasive procedure. The hospital’s use of the “Pre-Procedure Hand-Off” checklist provides the documentation required to demonstrate compliance with the standard. Because of the criticality of this standard, I recommend a focused medical record review to measure compliance with the use of the pre-procedure checklist. If the audit reveals the checklist is completed consistently, full compliance with the standard will be verified and no further action will be required.…
Anything abnormal needs to be reported to the doctor. These findings need to be documented as well. Document allergies according to facility policy. Accurate measuring and recording of height and weight are important for proper dosage of anesthetic agents. Ensure that the results of all laboratory, radiographic, and diagnostic tests on the chart. Document any abnormal results, and report them to the surgeon and the anesthesia provider. If the pt. is an autologous blood donor or has had directed blood donations made, those special slips must be included in the chart. Record a current set of vital signs within 1 to 2 hours of the scheduled surgery time, and document any significant physical or psychosocial observations. Report special needs concerns, and instructions (advance directives) to the surgical team, as required by The Joint Commission’s NPSGs. For example, advise the surgical team if the pt. is a member of Jehovah’s witnesses and does not accept blood products or if the patient is hard of hearing and does not have his or her hearing aid. This information assists the surgical team in providing continuity of care while the pt. is in the surgical area.…
She will be instructed not to eat or drink to minimize the risk of complications such as pulmonary aspiration and vomiting during the operation (Liddle, 2014). Before Audrey goes to the operating room, nurses must check the contents of the medical record to be sure that appropriate laboratory result are available as well as her fluid balance charts, medications and x-ray results. Also, nurses must ensure that informed consent has been obtained, as it is a medical-legal and clinical aspect of health care practice and the current progress notes must be charted as well as her allergy for Bactrim. Current vital signs must be taken and recorded as well. If pre operative vital signs are abnormal, notify the doctor straight away as it may increase Audrey’s surgical danger. Basic personal hygiene such as bathing will be performed or applying antiseptic agent on the skin at the incision site. It lessens the number of bacteria on the skin and reduces the risk of developing surgical site infection. Also, mark her left hip for the incision site. Audrey will also be checked and documented for any prosthetic device such as dentures and hearing aids to prevent damaging of the item during the surgery. Moreover, pre operative medications will be administered as per doctor’s order to reduce Audrey’s anxiety, lessen the chances of having nausea and vomiting and respiratory tract secretions (Taylor, 2009). Lastly, promote a restful and comfortable environment and offer her a…
Your surgeon may ask you to have a medical checkup by your primary care physician to ensure that you’re in good enough health for surgery. She will likely tell you to stop taking certain medications, like aspirin and non-steroidal anti-inflammatories, as these can cause excess blood loss during and after surgery and they may also interfere with the effects of anesthesia. She may also advise you to stop smoking as it can put you at a high risk of serious post-surgical complications. Because you’ll have difficulty moving comfortably after surgery, you should make sure that someone can come to your home to help you with activities like housecleaning, laundry and shopping.…
Luis is a 32-year-old male who immigrated to the U.S. when he was 14. He later became a US citizen. Although, Spanish is his native language, he speaks English extremely well. He recently returned to living with his parents after being laid off from being a semi-skilled auto worker 6 months ago. Luis is the middle of three children. He has a younger sister and older brother, his brother is away at college. Just prior to being laid off, he became involved with a young woman he claims is “the woman I’m going to marry.” He lives with his parents after being laid-off 6 months ago when he was living with friends. He was able to find a job where he works as a pizza delivery person. His mother was diagnosed with depression following the family’s move from Puerto Rico. Luis completed high school and one year of vocational training.…
Before entering the perioperative environment, hands should be primarily clean. The fingernails should be short. The area under any finger nails of length acts as a breeding ground for bacteria and increases the risk of cross infection (Jeanes and Green 2001). Nails should also be devoid of any nail polish or type of acrylic. All jewellery should be removed and arms should be bare below the elbow. (Weston 2008).…
Jan Williams needs for mental health services became more apparent, she could no longer overlook the need for services. She looked through the yellow pages of the phone book at the various providers and found a company by the name of St. Mary’s Home Care Agency, Inc. that provided an array of services, one to include Outpatient Mental Health services. She called the number and requested help for her special needs, because she was hearing voices and her mood swings were horrible. To start the process the secretary forwarded her call to the Intake Specialist, who in turn asked her some personal questions for the referral process. Some of the answers included her name, date of birth, address, telephone number and an emergency contact number.…
I would being by asking Mr. and Mrs. Lawson basic questions concerning the family’s history regarding any similar symptoms that other family members may have displayed. I would also ask if there were any changes in the family setting, such as relocating or if other family members have recently relocated. I would also ask Mr. and Mrs. Lawson specific details about the symptoms regarding Clara’s eating patterns, and sleeping patterns, and how long this has been occurring. I would also engage Clara into conversation, so that her direct responses could be included in the conversation, so that I would have a better understanding on the lack of eye contact when talking.…
In order for an individual to get help with alcohol or substance use or abuse and begin the process of rehabilitation, an accurate clinical assessment is needed. A proper diagnosis and treatment plan can only be formulated when all historical and current relevant information has been considered. Angela, a 32-year-old woman should be assessed by considering her past and current use and abuse of alcohol and other substances. Additionally, Angela should be assessed by looking into her attitudes and behaviors towards substance abuse, her social and occupational functioning, her finances and familial relationships, and her legal, health and spiritual histories. Finally, a diagnostic impression should be formulated and recommendations for treatment…
Smeltzer, S. C., & Bare, B. G. (2004). Brunner & Suddarth 's Textbook of Medical Surgical Nursing. (10th ed.). Philedelphia: Lippincott Williams & Wilkins.…
Mr. and Mrs. Lawson brought their 4-year-old adopted daughter, Clara, to see Dr. Mason, a psychiatrist. Clara was polite in greeting Dr. Mason, but did not smile and kept her gaze down as she took a seat. Mr. and Mrs. Lawson sat next to Clara and began explaining their concerns. They described Clara as a quiet child who has recently begun throwing temper tantrums, during which she is inconsolable. Her sleep and eating patterns have changed, and she no longer wants to go to preschool.…
First, I would like to say thank you for reading this letter. I am a college student enrolled in a teacher education program. This program requires all teacher candidates to complete a series of preclinical classroom experiences prior to student teaching. I am required to do 60 hours of Pre-Clinical Observation at a school in a general education 1st through 5th grade classroom in September. I am writing this letter to ask if I could complete my observation hours at Puyallup Cascade Christian School. This would be a great honor and opportunity for both my personal and academic endeavors.…
MITCHELL, M., 2008. Patients’ perceptions of pre-operative preparation for day surgery. Journal of Advanced Nursing, 26(2), pp. 356-363.…
When you are having surgery, one of the preoperative subjects that your Glendora General Surgery will discuss with you is how long you need to fast before your surgery, and when you need to reduce or stop your dietary supplements or medications, especially if you are going to have a general anesthesia or another form of sedation. It is also important for you to understand why you need to strictly adhere to your surgeon’s advice. How long you will need to fast or restrict the use of medicines and supplements will vary depending on your age, the type of your operation, and your personal health history.…