2Complex Patient Case Results PDF

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Health and Illness Across the Lifespan...

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Complex Patient Case Results Doris Turner ShadowHealth

Patient Assessment

Finding: Checked blood glucose before giving medication Pro Tip: Since your patient is receiving insulin for her diabetes, it is important to assess her blood sugar before and after administration monitor for intended therapeutic effect and hypoglycemia. Example Question: Finding: Asked sulfa reaction type Pro Tip: Assessing the reaction type and severity of a stated allergy may help inform your care plan and determine which medications are appropriate to administer. Example Question: How does your body react to sulfa? Finding: Asked for patient identification Pro Tip: Proper identification is critical for the protection of your patient. It is recommended to check two identifiers before interacting with the patient. Example Question: What is your name and birthday? Finding: Asked about general experience with side effects Pro Tip: When administering routine medications, understanding the side effects that the patient generally experiences can shape your care plan to ensure patient safety and comfort.

Example Question: What medication side effects have you experienced? Finding: Asked about medication allergies Pro Tip: Patients may have allergies that are not included in their documentation, so asking for verbal confirmation can prevent serious adverse events. Example Question: Do you have medication allergies? Finding: Checked vitals before giving medication Pro Tip: Assessing the patient's vitals may impact your care plan and the safe administration of ordered medications. Example Question: Finding: Asked about breathing Pro Tip: As your patient is suffering from pneumonia, it is important to assess breathing status to identify worsening symptoms or life-threatening respiratory complications. Example Question: Have you had breathing problems lately? Finding: RLL with crackles, all other lobes clear to auscultation before medication Pro Tip: Auscultation of your patient's lungs is important to assess for worsening symptoms of her pneumonia. Example Question: Finding: Asked about orientation to place and time

Pro Tip: Many of the patient's ordered medications carry the risk of confusion as an adverse effect; it is also important to assess geriatric patients for the onset of age-related conditions such as dementia. Example Question: Do you know where you are right now? Finding: Asked about comfort Pro Tip: Assessing your patient's comfort level during her hospital stay is an important administrative best practice; addressing her concerns about comfort may enhance her general well-being and the efficacy of treatment. Example Question: Are you comfortable? Finding: Asked about ability to use bathroom Pro Tip: Since your patient is part of the geriatric population, it is important to assess her ability to get to the bathroom and walk independently. Example Question: Do you need help getting to the bathroom? Finding: Asked about mobility Pro Tip: Since your patient is part of the geriatric population, it is important to assess her ability to get to the bathroom and walk independently. Example Question: Do you have problems walking? Finding: Asked about thirst Pro Tip: Thirst can be an important indicator of the patient's general comfort and recent intake. Excessive thirst may be an indicator of dehydration. Example Question: Are you thirsty?

Finding: Checked intake and output before giving medication Pro Tip: Assessing the patient's intake and output may impact your care plan and the safe administration of ordered medications. Example Question:

Patient Monitoring

Finding: Asked about swelling Pro Tip: Swelling can be an indicator of an allergic reaction to medication. Example Question: Have you noticed swelling anywhere? Finding: RLL with crackles, all other lobes clear to auscultation after medication Pro Tip: Auscultation of your patient's lungs is important to assess for worsening symptoms of her pneumonia. Example Question: Finding: Asked about IV site Pro Tip: Assessing the patient's IV site is an important patient comfort consideration and may reduce the risk for IV site complications such as infection. Example Question: How does your IV site feel? Finding: Asked about confusion Pro Tip: Many of the patient's ordered medications carry the risk of confusion as an adverse effect; it is also important to assess geriatric patients for the onset of age-related conditions such as dementia.

Example Question: Do you feel confused? Finding: Checked vitals after giving medication Pro Tip: Assessing the patient's vitals may impact your care plan and the safe administration of ordered medications. Example Question: Finding: Checked blood glucose after giving medication Pro Tip: Since your patient is receiving insulin for her diabetes, it is important to assess her blood sugar before and after administration monitor for intended therapeutic effect and hypoglycemia. Example Question: Finding: Asked about breathing (Available) Pro Tip: As your patient is suffering from pneumonia, it is important to assess breathing status to identify worsening symptoms or life-threatening respiratory complications. Example Question: Have you had breathing problems lately? Finding: Asked about shakiness Pro Tip: Shakiness may be an indicator of low blood sugar, which is a life-threatening adverse effect associated with insulin. Example Question: Do you feel shaky? Finding: Asked about headaches

Pro Tip: Headaches are one of the most common adverse effects associated with venlafaxine. Example Question: Do you have a current headache? Finding: Asked about abdominal pain Pro Tip: Abdominal pain, especially abdominal cramping, is one symptom of pseudomembranous colitis, which is a life-threatening adverse affect associated with ceftriaxone. Your care plan should also include instructions to monitor for these symptoms throughout and shortly after antibiotic treatment. Example Question: Do you have any stomach pain? Finding: Asked about nausea Pro Tip: Nausea is one symptom of pseudomembranous colitis, which is a life-threatening adverse affect associated with ceftriaxone. Your care plan should also include instructions to monitor for these symptoms throughout and shortly after antibiotic treatment. Example Question: Are you feeling nauseated? Finding: Checked intake and output after giving medication...