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AM shift 09/09/19 (Patient 16b (Patient admitted with polyuria causing…
AM shift 09/09/19
Patient 16b
Patient admitted with polyuria causing hypokaelmia post pituitary gland resection. Pt requires strict hourly FBC input/output. Routine referral to OT for assessment. Admission paperwork is completed. Assessed for falls risk, braden scale, 4at. Low risk, prevention required. Obs taken, pain score discussed. Reg meds given and educated on same, PRN paracetamol and codiene given for 8/10 headache.
Communication within the MDT, an accurate handover of the patient is provided prior to the OT conducting their assessment for the best outcome for the patient.
Nursing assessment skills are utilized to determine the patients risk level, tools are utilised to guide this practice.
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Patient 16c
Patient admitted with cellulitis and fluid overload secondary to CHF. Pt for daily weigh, obs, MSU, IV frusemide BD, pre meal BGL. The pt's mobility was assessed to determine whether their mobility had deteriorated from their baseline prior to admission. They required their R) leg to be assessed, dressed and for the wound to be documented. Communication with the house officer was required to have laxatives charted as BNO 2/7.
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Patient 16d
The pt was made for comfort cares after the medical team rounds. From here the Te Ara Whakapiri was started. As the family was Maori there was close contact with the family about plans for palliation outside of the hospital.
Cultural safety and treaty of Waitangi is considered with this patient. Ensuring a holistic care plan is developed for this patient.
Communication, comfort and reassurance with the patient and family is essential to build trust and rapport.
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Patient 10
Patient was admitted to the medical ward with a pneumonia. They required 4hrly obs, 2L O2 via NP, IVF due to poor oral intake and regular nebs. And IVAB's. This patient was given education on the correct use of an inhaler using a spacer.
Education provided allowing the patient to participate in their care. This improves the patients health literacy for best health outcomes in the future.
Skills in medication administration is demonstrated through neb and IVAB administration with preceptor supervision.
Patient 12
Patient admitted to the ward post fall for monitoring of neuro statis. Obs, lying and standing blood pressures and neuro obs completed on this patient. Regular meds were given. Showering this patient is delegated to the HCA. An assessment of mobility was completed and this was referred to the physiotherapist.
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Observed for vital signs, postural hypotension, neuro statis and mobility.
Trendcare completed, concerto updated, notes written and verbal handover given to PM shift.
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