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Week 8 patient load - Coggle Diagram
Week 8 patient load
Patient 5
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The patient was admitted to the ward with a surgical wound infection one week after being discharged following a L) mastectomy.
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The patient was being nursed in contact isolation after a wound swap returned positive for MRSA. The patient had a wound drain insitu, the wound output was recorded on a wound chart. The patient was being treated with twice daily oral antibiotics. She could eat and drink.
The doctors cleared the patient for discharge home on oral antibiotics and with the wound drain. The discharge paperwork and a script for oral antibiotics was given to the patient. Her dressing was changed to be waterproof for easier showering at home and her IV canula was removed. The patient was educated on emptying the drain bottle.
A district nurses referral was completed for wound and drain care at home and a follow up appointment was made for the drains removal in one week. The patient was picked up by her husband. The patient's notes were completed, discharge checklist was completed and her own medications were returned. The old notes and file were put together and given to the ward administrator.
Patient 4D
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The patient was admitted with right iliac fossa (RIF) pain which was raising suspicion of appendicitis, which was determined by an ultrasound.
The patient had a medical background of ischemic heart disease-stent was inserted in 2005, epilepsy, sleep apnea and a recent cholecystectomy.
The patient's diagnosis was being effectively managed with IV antibiotics and it was determined the patient did not require surgical intervention. The patient required 4 hourly observations, IV antibiotics-cefuroxime and metronidazole. CPAP overnight and was able to eat and drink as tolerated.
Following ward rounds the doctors cleared the patient for discharge home on oral antibiotics. The patient's paperwork and script were completed and given to the patient. The patient was advised to return to hospital if the pain worsened or began to experience further symptoms or complications.
The patient's IV cannula was removed. His own medications were returned. His wife was rung to update her of the plan to discharge and she came to pick the patient up. All paperwork and documentation was completed including clinical notes, discharge checklist and care plan. The patient's file, old notes and charts were then gathered and given to the ward administrator for sorting and storage.
Patient 4A
Admitted with low grade rectal pain which severally increased with bowel motions post stapled haemrroidectomy 1 week prior.
Medical background: Anaemia, appendicectomy, bilateral hernia repair.
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Patient required 4 hourly observations, IV antibiotics, IV fluids as he was NBM since 0200 for theatre, regular laxatives and pain management.
The patient required to be prepared for theatre. This included completing the pre-operative checklist, ensuring he had a shower, the correct TED stocking on, an OT gown and the removal or taping of jewelry (wedding ring). The patient has also been NBM since 0200 that morning.
Patient 4C
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New Admission for ED with possible pancreatitis. He had a medical history of hypocholesteremia, hypertension and type two diabetes-insulin controled.
Handover was received from ED over the phone then transferred to the ward. The patient was orientated to the ward and bed space. The patient required 4 hourly observations including one on arrival. The patient was NBM for a ultrasound at 1300 hours. He required 4 hourly BSLs, IV fluids.
The patient's admission forms were completed and was assisted to put TEDs on. The patients own medication was stored in the medication room-labeled correctly. The patient also had family present who were oriented to the wards Whanau room where they could have tea/coffee or milo. The family were involved and kept informed of the patients care as requested by the patient.
Due to the patient's diagnosis, IV fluids and being NBM a strict fluid balance chart was commenced and the patient was given a urine bottle for measuring urine output. The patient was to begin with a clear oral fluids only diet following the USS.
patient 4B
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The patient required 4 hourly observations, fluid balance for IDC output, pain relief, and to be prepared for discharge that morning.
The patient was cleared for discharge following doctors rounds. The patient's discharge summary and script was completed by the team which was given and explained to the patient. A follow up appointment to have the IDC removed in 2 days was made in outpatient clinic, the patient's IV cannula was removed and his IDC bag was changed to a leg bag to make going home easier. The patient was given a night bag attachment and education for the care of a IDC was given.
The patient was picked up from the ward and all documentation was completed including clinical notes, discharger checklist. All paperwork, files and old notes were then handed over to the ward administrator for correct storage.
Trend Care, clinical documentation and care plans were updated.
Various communication skills were utilized throughout the shift. professional communication was used when discussing patient care with preceptor, doctors and other members of the MDT. Also at handover to the next shifts nurses.
Effective communication was used to communicate care with the patient. Communication is essential to build trust and rapport with both the patient and their family.