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Publié par | eBookIt.com |
Date de parution | 09 janvier 2011 |
Nombre de lectures | 0 |
EAN13 | 9781456600433 |
Langue | English |
Informations légales : prix de location à la page 0,0400€. Cette information est donnée uniquement à titre indicatif conformément à la législation en vigueur.
Extrait
Orthopedic Inpatient Protocols
A Guide to Orthopedic Inpatient Rounding
by
Miriam Wiggins
Copyright 2011 Miriam Wiggins,
All rights reserved.
Published in eBook format by eBookIt.com
http://www.eBookIt.com
ISBN-13: 978-1-4566-0043-3
No part of this book may be reproduced in any form or by any electronic or mechanical means including information storage and retrieval systems, without permission in writing from the author. The only exception is by a reviewer, who may quote short excerpts in a review.
Important Notes
This book should be used only as a general guide for providers of inpatient orthopedic care. Different hospitals and attending surgeons may vary in regards to specific protocols and medication formularies. Please check with your attending to be sure that the content of this book meets their specific standards of care.
SOAP Note
When rounding, notes written in the patient’s chart may be written in the SOAP note format:
S: Patient subjective findings (pain, SOB, CP, etc.)
O: Patient objective data (Vital signs, lab data, Is & Os, physical exam findings, etc.)
A: Assessment (POD# and surgical procedure, medical issues/conditions, other injuries, etc.)
P: Plan (PT, WBS, medications, DVT prophylaxis, NPO for OR today, etc.)
Daily Rounding
Print All Patient Lists
Organize and prioritize lists
Service patient vs. consult patient
New admissions
POD#
Planned discharge day
Note all injuries and procedures
Note all laboratory, radiology and diagnostic study results
Note weight bearing status and spinal precautions if applicable
Check code status
Gather Objective Data
Note pertinent recent data to include:
vital signs
cardiac rate and rhythm if on telemetry
Is & Os
Lab values
Culture results and sensitivities
Check to make sure appropriate antibiotic is ordered.
Antibiotics ordered, day #/total # of days ordered
When rounding on each patient:
Review the chart including the most current attending note for the plan, and the previous 24 hrs of RN progress notes for any issues.
Ask patient regarding the following, and address any issues or concerns:
pain control
nausea/vomiting
chest pain
shortness of breath
voiding
last bowel movement
Assess mental status
Alert and oriented X person, place, time and situation vs. lethargic, confused or agitated.
Cooperative vs. combative
Chec