A 93years old female is brought in by ambulance due to mechanical falls at home while going to the bathroom. Primary diagnosis left hip dislocation .Secondary diagnosis: Hypertension hyperlipidemia, heart burn.Plans: Pain control ,use of incentive Spirometry 1hour while awake. Left hip fixation with DHS.( Dynamic Hip Screw) Dressing to the left hip intact. Physical therapy evaluation and treatment. Dangle feet at bedside. WBAT(Weight bearing as tolerated).SCD right lower Extremity. Physical therapy ambulate with patient. Discharge plan: Patient will be discharged to SNF with parameters. Keep wound clean and dry. Follow up with laboratory tests, procedures and treatment. Follow up with Orthopedic surgeon in ten days.Medication while in hospital are Coreg,Hydrochlothyzide, Lovenox 30mg, Rocephin 1gm,Ambien, morphine 2mg IV Q6hours,Norco 10/325mg Po Q4hours prn pain. Tylenol 650mg po Q6hours prn temperature.
5 Aug 2021
DISCHARGE PLANNING/ INSTRUCTIONS.
Patient discharge starts upon admission. The patient will be informed early during their care process about their discharge to go home, or Skilled Nursing Facility or transfer to another hospital, or discharge to hospice. Patient discharge planning will include how patient can manage symptoms at home,pain medications, nausea/Vomiting medication, blood pressure medications. The emotional needs and support addressed. Transportation needs, family pick up or ambulance service pick up.Patient discharge to go home is done by the doctor atleast a day before the date of discharge and the nurse will initiate it a day early to make sure that patient discharge needs are met.Written instructions will be given to patient and family.No medical abbreviations on the discharge teaching.Medications reconciliation done. Do not tamper with medical records. Don't criticize other healthcare professionals in your charting.Enter all information in a complete relevant, accurate and factual manner. Avoid bias from written description of others. In discharging a patient with stroke for example educate patient on a healthier lifestyle. For example stop smoking( Recommend gums)reduce alcohol intake ( Give your patient phone number for AAA anonymous),reduce stress, take your medications as ordered, get 30minutes regular exercise every day. Take your medications as prescribed by the doctor. Check your blood pressure regularly document findings and take it to next doctor appointment. If patient is transferred to another hospital or Skilled Nursing Facility arrangement will be made for ambulance service to pick patient to the new facility or hospital at a specific time.Patient must must be cleaned and ready to go to the new facility with all patient belongings. Information about patient fax to the new facility. When ambulance arrive nurse will give report to the EMT team that came to pick up the patient. Case manager is the healthcare professional that made arrangements for the transfer according to the doctor orders.
3 Aug 2021
ADMISSION THROUGH EMERGENCY ROOMS.(THREE CASE SCENARIOS. EIGHT YEARS OLD,69YEARS MALE AND 70YEARS)
Admissions of patients using three case scenarios. Eight years old boy is brought into Emergency room due to pain in left ear and fever.Upon arrival to Emergency room triage and place in room D.Vital signs done temperature 103.2.Saline lock started IV fluid given 0.9NS bolus 500ml,antibiotic IV given ,tylenol 15ml liquid suspension given po.Recheck temperature 97.6.Doctor gave prescription of Agumentin and tylenol. Patient and his mother receive a printed education materials through Krames upon discharge and is asked to follow up in two weeks with his Pediatrician but mother said that her son has no Pediatrician. The nurse gave her a list of Pediatricians and ask her to choose one,call and follow up in two weeks. So they left.He was not admitted. The next case SCENARIO is a 69years old man with facial tumors who went to surgery from Emergency room for Excision of tumors.The third case scenario is a 70years female with ejection fracture of 40%, came in due to left hip dislocation.(Fell at home) Patient will be admitted to Trauma Unit.
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