WCU Telenursing Script and Documentation PDF

Preview

Summary

it's good...

Description

West Coast University Telenursing Script INITIAL CONTACT Introduction: Identify self: “Hi, my name is

and I am a Registered Nursing student at

West Coast University. I would like to speak with you about your health and wellness needs”. Identify Preferred Mode of Communication: “Do you prefer phone call or video call? Is this a good time to talk?” Identify focus area: Health topics such as nutrition, medical issues/primary health concern, medication, resources, medical provider, health teaching, medication reconciliation care plan Administer Health Assessment Questionnaire: Assessment of learner: Home/Community/ Client“How have you been feeling lately? Do you have any medical problems? What medications are you taking? Are you taking them daily? How are you getting your medications from the pharmacy? Who do you live with? Do you know how to contact your primary care provider? Do you have access to healthy food? What is your diet like? Are you able to safely shelter in place? Do you have any specific concerns? Do you feel like you have everything you need? Do you feel you are able to stay healthy and safe during this pandemic?” Additional questions may be asked as needed. How would you rate your current stress level? What stress management techniques have worked for you in the past? Are they available to you now? What alternate stress reduction modalities will you employ? Additional questions may be asked as needed: “How are you feeling this week? Do you still feel like you are able to stay safe and healthy? Are you having any new concerns you would like to discuss?” Address specific education provided. Address any needs. For example, if the patient had previously mentioned that they take their blood pressure medicine “sometimes”, ask if the patient has been taking it daily or has reached out to their primary care doctor. Ask if patient reached out to any community resources that were suggested during the last conversation (if applicable). Implement Educational/Teaching Plan- Individualized educational/teaching plan based on client needs: Health Teaching (use weekly objectives to direct case conferences), COVID 19 care plan, referrals to appropriate agencies, active listening, and support. Allow time for patient to ask questions. Conclusion of Meeting/Plan for Follow up: “Thank you for speaking with me today. I enjoyed getting to know you and helping you. I look forward to speaking again next week.” “I would like to follow-up with you next week. Do you have a preferred day and time for me to call?” FOLLOW UP CONTACT Introduction: “Hi, it’s Registered Nursing student from West Coast University. I enjoyed speaking with you last week. I wanted to check in and see how things were going.” Evaluation of educational plan. Plan for Follow up: “Would you like another follow-up call next week?”

Provided by College of Marin

Provided by College of Marin

Telenursing Initial Patient Call Form Patient Initials Age Date of Communication Verbal Consent LB 29 9/5/20  One person on call + More than one person on call

Medical History Pneumonia 7th grade

Current Medications ZOFRAN /ONDANSETRON MORPHINE

Social/Living Situation Marital status: Has a husband. Where do they live? (House, apartment, assisted living, SNF, homeless, etc.) Lives in a house. Who do they live with? Lives with husband. Is the living situation stable? Are they able to maintain safe distance from others if not in private home? Are there any concerns about home environment? Stable living situation. Maintains safe distance from others. No concerns about home. Mobility status: Has a cast. Access to medical care? Has access to medical care. Access to food/water? Has access to food and water. Access to medications? Has access to medications. Financial concerns? No financial concerns.

Provided by College of Marin

Telenursing Clinical Assignment Patient Initials LB

Age 29

Date of Communication 9/5/20

Initial or Follow-up? Initial

Describe any patient needs you identified in your patient. List in order of highest priority to lowest priority: LEFT RIB PAIN LEFT LEG PAIN C-COLLAR PLACED

Were there any emergent needs and how did you address them? Patient has pain when they take deep breaths. Encouraged patient to use incentive spirometer.

What patient teaching resources did you present to your patient? Education regarding incentive spirometer, cast management, medication.

What interventions did you identify that may be helpful for your patient? What did you suggest? Incentive spirometer to promote healthy breathing. Were you able to involve family, and if so, how? No family members were involved.

What patient-specific questions may you want to ask the next time you speak with this patient? Would like to ask patient regarding occupation and issues that may arise due to the injuries. Also would like to ask patient regarding level of pain they are experiencing.

What community resources, if any, did you recommend? Did not recommend any community resources. Provided by College of Marin

How did you feel while speaking with this patient? I felt comfortable as patient was very easy to talk to and forthcoming. She had a very friendly demeanor and was welcoming to conversation.

Provided by College of Marin

Telenursing COVID-19 Care Plan Example Nursing Diagnosis Risk of falls AEB_left leg pain___,__cast___

Outcomes Patients will m ai ntain stab ility w hile gettin g up and walk ing. Patient will demonstrate appropriate body mechanics for moving with a cast.

Risk for acute pain AEB_injury to soft tissue.

. Patient will verbalize a reduction of pain. Patient will display a relaxed manner. Patient will demonstrate ability to participate in activities with minimal complaints of discomfort.

Provided by College of Marin

Interventions Place patient on an orthopedic bed. Support affected area with pillows and folded blankets.

Evaluation Patient will experience a higher level of comfort by the end of shift. Patient will experience a higher level of comfort by the end of shift.

Assess and record the patient’s level of Patient will pain utilizing a 0-10 indicate mild to no scale. pain by the end of shift. Encourage patient to discuss problems Patient will address related to the injury. emotional and physical stress by Elevate and support the end of shift. injured extremity. Patient will indicate higher comfort in regards to injured extremity by the end of shift.

References Hickling, E. J., & Blanchard, E. B. (2006). Overco ming the trauma of your motor vehicle accident : a cognitivebehavioral treatment program, workbook (Ser. Treatments that work). Oxford University Press.

Nursing Diagnosis Impaired gas exchange as evidenced by left rib pain.

Outcomes

Interventions

Patient will Monitor respiratory maintain adequate rate and effort. respiratory function. Auscultate breath sounds, noting the development of unequal, hyperresonant sounds. Note increasing restlessness, and stupor.

Provided by College of Marin

Evaluation Patient will exhibit proper use of an incentive spirometer by the end of shift. Patient will exhibit normal breath sounds by the end of shift. Patient will be at ease and well rested by the end of shift.

References

West Coast University Telenursing Student Tracking Tool Fall I 2020

Patient Initials LB

Age

29

Contact number N/A

Provided by College of Marin

Nursing/ Education topics Incentive spirometer

Comments

ER nurse

Date and time of initial call 9/5/20

Date and time of follow-up calls N/A

Number of hours 6

Provided by College of Marin...