Chapter 4, Problem 32R

Rewrite the following statements using the appropriate language for nursing documentation. Patient is being very unreasonable and impatient; pt. states that he is extremely anxious and needs his prn anti-anxiety med and says he is mad that the RN has been ignoring the call light. Patient does not appear anxious – he is just complaining b/c he doesn’t like to be alone for too long in his room.

Medication List: This should include ALL medications your patient is currently taking. (Attach additional sheets if necessary) Medication Name (Trade and Generic) and Drug Class Dose (with appropriate units) /Route/Time Ordered (ex: 30mg PO 1xD 8am) Why is YOUR patient on this medication? (Indication) Normal Dose Range for Indication Required nursing interventions for THIS medication in THIS patient. Pre/Post administration physical assessments, pertinent labs, specific time to re-evaluation effectiveness. Is this a home med? Y/N These are the medication Entresto 49/51mg Toprol XL 100mg Lasix 80mg Farxiga 10mg Atorvastatin 80 mg Spironolactone 50mg Patient lab work UWBC: 100,000 BUN/Creat: 60/3.0 GFR: 40 K+: 5.9 Na+: 135

Rewrite the following statements using the appropriate language for nursing documentation. Patient complaining about the number of pills prescribed to him by the doctor – the patient is at high risk for medication noncompliance because he does not care about his own well-being.

The nurse decides to call the physician and receives a verbal order for “Give Sally Smith 5 mg morphine sulfate q6h PRN for pain.”  The nurse should do the following actions.  Select all that apply: Check medication rights and allergies prior to administering the medication Document the verbal order in the electronic medical record Ensure the verbal order is signed by the provider within 24 hours Ask the provider for additional order information Perform a check-back and verbally repeat the providers order while still on the phone

A Patient with family history of a hematologic condition is being seen by a nurse. What assessment funding needs additional assessment for the condition.

Identify three nursing interventions with associated rationale for the concern listed above. You and your fellow nursing assistant are completing ADLs for a dependent patient. You have given a bed bath and changed the occupied bed, and it is now time to reposition a dependent patient.

Case:Location: Medical-Surgical UnitTime: 0800Report from night shift charge nurse:Situation:Sara Lin is an 18-year-old patient who had an emergency appendectomy. It is day 2 postoperative, and Sara is expected to be discharged late this afternoon. We have discontinued her IV antibiotics after her morning dose. She will be getting oral meds today.Background:Sara presented in the ED 2 days ago with a 2-day history of nausea, vomiting, and increasing pain. She was taken to surgery that day and had an open appendectomy for a ruptured appendix. She has been stable since arriving to the unit. Her parents have been here with her most of the time and are very helpful and supportive.Assessment:Sara is alert and oriented. She needs to be reminded to use her incentive spirometer. Abdomen is soft and tender to touch. Bowel sounds active. She has progressed to regular diet, and she's eating small amounts. No nausea reported since postoperative day 1. The surgery team changed the abdominal dressing…

Case:Location: Medical-Surgical UnitTime: 0800Report from night shift charge nurse:Situation:Sara Lin is an 18-year-old patient who had an emergency appendectomy. It is day 2 postoperative, and Sara is expected to be discharged late this afternoon. We have discontinued her IV antibiotics after her morning dose. She will be getting oral meds today.Background:Sara presented in the ED 2 days ago with a 2-day history of nausea, vomiting, and increasing pain. She was taken to surgery that day and had an open appendectomy for a ruptured appendix. She has been stable since arriving to the unit. Her parents have been here with her most of the time and are very helpful and supportive.Assessment:Sara is alert and oriented. She needs to be reminded to use her incentive spirometer. Abdomen is soft and tender to touch. Bowel sounds active. She has progressed to regular diet, and she's eating small amounts. No nausea reported since postoperative day 1. The surgery team changed the abdominal dressing…

Case:Location: Medical-Surgical UnitTime: 0800Report from night shift charge nurse:Situation:Sara Lin is an 18-year-old patient who had an emergency appendectomy. It is day 2 postoperative, and Sara is expected to be discharged late this afternoon. We have discontinued her IV antibiotics after her morning dose. She will be getting oral meds today.Background:Sara presented in the ED 2 days ago with a 2-day history of nausea, vomiting, and increasing pain. She was taken to surgery that day and had an open appendectomy for a ruptured appendix. She has been stable since arriving to the unit. Her parents have been here with her most of the time and are very helpful and supportive.Assessment:Sara is alert and oriented. She needs to be reminded to use her incentive spirometer. Abdomen is soft and tender to touch. Bowel sounds active. She has progressed to regular diet, and she's eating small amounts. No nausea reported since postoperative day 1. The surgery team changed the abdominal dressing…