Orthopedic Inpatient Protocols
19 pages
English

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19 pages
English

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Description

This book is intended to be used as a general guide for physician residents, physician assistants, and nurse practitioners regarding inpatient care and management of orthopedic patients.

Information is included to provide comprehensive patient care from admission to discharge, with sections dedicated to SOAP notes, daily rounding, medical complications, neurological exams, complex regional pain syndrome, and treatment options.

Sujets

Informations

Publié par
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

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