patient profile instructor copy robin ritter
TRANSCRIPT
![Page 1: PATIENT PROFILE INSTRUCTOR COPY ROBIN RITTER](https://reader036.vdocuments.site/reader036/viewer/2022071613/6157d524ce5a9d02d46f977f/html5/thumbnails/1.jpg)
7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
ROBIN RITTER
PATIENT SUMMARY Admitted with Total Hip Replacement (THA) - post-op day #3. Patient has a history of angina and requires
sublingual nitroglycerin. Colace is ordered but no BM since before surgery. Also requires administration of subQ heparin and clarification of pain medication.
LEARNING GOALS
• Identification of additional information required from report
• Correct dosage calculation• Correct administration of subQ, sublingual and
PO medications• Documentation of medication administration• Effective SBAR communication with prescriber
• Identification of priority nursing assessments for patient with angina and THA
• Interpretation of lab results for postoperative patient receiving heparin
• Creation of appropriate 5-minute nursing care plan for patient with angina and THA
• How to complete medication error report if needed
PATIENT PROFILEINSTRUCTOR COPY
![Page 2: PATIENT PROFILE INSTRUCTOR COPY ROBIN RITTER](https://reader036.vdocuments.site/reader036/viewer/2022071613/6157d524ce5a9d02d46f977f/html5/thumbnails/2.jpg)
7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
PATIENT PROFILE - Robin RitterInstructor Copy
• Heparin 50,000 units/5 mL• Heparin 10,000 units/10 mL (Distractor)• Colace 100 mg tablets• Nitroglycerin sublingual spray• Nitroglycerin sublingual tablets (Distractor)• Oxycodone 5 mg/Acetaminophen 325 mg tablets
(controlled substance - count)
• SubQ syringes• Medication cups• Alcohol wipes• Injection training pad
Medications Required: Additional Supplies Needed:
1
Medications Required:
Additional Supplies Needed:
SKU MEDICATION / ITEM QUANTITY PRICE
PM087803 Practi-Heparin™ 10,000 USP/10 mL (1,000 U/mL) 10 $59.95 / Box of 40
PM087804 Practi-Heparin™ 50,000 USP/5 mL (10,000 U/mL) 10 $62.95 / Box of 40
PM117805 Practi-Docusate™ Oral Medication 10 $14.95 / Box of 48
PM127805 Practi-Nitroglycerin Spray™ 1 $39.95 / Box of 5
PM117834 Practi-Nitroglycerin™ Oral Med 1 $24.95 / Box of 5
PM117814 Practi-Oxycodone & Acetaminophen™ Oral Medication 10 $14.95 / Box of 48
SKU MEDICATION / ITEM QUANTITY PRICEMED051026 3 mL Luer Lok Syringe with Safety Needle 10 $14.95 / Box of 50
MED051460 3 mL Luer Lok Syringe with Safety Needle 10 $19.29 / Box of 50
MED111001 3 mL Syringe with Blunt Vial Access Cannula 10 $37.49 / Roll of 100
MS081023 Plastic Medicine Cups 10 $1.76 / Box of 100
MED081072 Alcohol Prep Pads 30 $18.50 / Box of 2,000
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7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
PATIENT PROFILE - Robin RitterInstructor Copy
2
TODAY’S LAB RESULTSWBC 10.4
RBC 4.8
HGB 7.2
HCT 38.1
PLT 358,000
RBS 66
Na+ 135
Cl- 97
K+ 3.5
• Allergies: Plavix, Restoril• Admitted with THA (total hip replacement)• Post-op day #3• Medical history: stable angina• VS: T 99.8 - P 88 - RR 22 - BP 102/64 -
pulse ox 91%• Lung sounds diminished bilaterally• No BM since before
surgery• Patient just asked
for medication to relieve angina chest pain
Patient Health & History
Additional Optional Supplies:
SKU MEDICATION / ITEM QUANTITY PRICEMS153901 SLS Small Injection Trainer 1 $19.95 / Each
DATE TIME PATIENT NAME # ON HAND # USED # LEFT SIGNATURE
Controlled Substance Count Sheet:
MEDICATION:
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7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
PATIENT PROFILE - Robin RitterInstructor Copy
3
Medication Specifications:
HEPARIN 5,000 UNITS SUBQ BID | Dosage Time: 0900, 1700DRUG CLASS: AnticoagulantREASON WHY PRESCRIBED FOR THIS PATIENT: Prevent postoperative DVT
TWO MAIN PRECAUTIONS/CONSIDERATIONS FOR THIS PATIENT WITH THIS MEDICATION:1. Monitor platelet count for HIT - assess for signs of bleeding2. Do not administer other medications that affect clotting3. Do not rub the injection site after administration - bruising at injection sites common
SHOULD IT BE ADMINISTERED AS WRITTEN? YESRATIONALE: Prevent DVT
COLACE 100 MG PO BID | Dosage Time: 0900, 1700DRUG CLASS: Stool softenerREASON WHY PRESCRIBED FOR THIS PATIENT: Immobility and pain medications cause constipation
TWO MAIN PRECAUTIONS/CONSIDERATIONS FOR THIS PATIENT WITH THIS MEDICATION:1. Stool softener only, not a laxative - do not confuse with Dulcolax 2. Take with a full glass of water or juice3. Encourage dietary fiber -teach patient to avoid Valsalva maneuver
SHOULD IT BE ADMINISTERED AS WRITTEN? YESRATIONALE: No BM since before surgery, laxative needed as well
NITROGLYCERIN SUBLINGUAL SPRAY - 2 SPRAYS Q 5 MINUTES | Dosage Time: PRN UP TO 3 TIMES PRN CHEST PAIN **LAST DOSE: NOT PREVIOUSLY GIVEN
DRUG CLASS: Antianginal vasodilatorREASON WHY PRESCRIBED FOR THIS PATIENT: Relieve angina chest pain
TWO MAIN PRECAUTIONS/CONSIDERATIONS FOR THIS PATIENT WITH THIS MEDICATION:1. Have patient raise the tongue and spray underneath2. May be repeated Q 5 minutes x 2 —> if still not relief call Rapid Response3. Monitor heart rate & BP - can cause headache (relieve with acetaminophen)
SHOULD IT BE ADMINISTERED AS WRITTEN? YESRATIONALE: Patient requests medication to relieve angina pain
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7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
PATIENT PROFILE - Robin RitterInstructor Copy
4
ADDITIONAL INFORMATIONWhat additional information is needed from the shift report?• IV access?• Activity order? How tolerated? PT consulted?• Diet? • Trend of CBC? • Oxygen ordered? Spirometer? Any SOB? Lung sounds? Cough/deep breathe?• SOB with activity? (anemia)• Type & cross done? Blood on hold? • Incision appearance? Drain?
Interpretation of lab results? • Elevated WBC - possible infection, probable inflammation after surgery, need to look at diff• Low hgb/hct/rbc - blood loss after surgery• Pulse ox - probable atelectasis
What are the key nursing assessments?• Chest pain - quality, onset, etc. • Lung sounds (diminished —> atelectasis)• Incision appearance• Activity tolerance, especially with anemia• Abdomen (constipation)
SBAR communication with physician:• Angina (if not relieved with NTG)• Oxygen (titrate to keep pulse ox > 95-98%)• Order for spirometer (if facility requires order)• Laxative order in addition to Colace• Change subQ heparin order to Q 12 hours• Clarify pain level for Oxycodone PRN (consider Tylenol for mild pain
OXYCODONE 5 MG/ACETAMINOPHEN MG 1 TABLET PO Q | Dosage Time: PRN 4 HOURS PRN PAIN **LAST DOSE: 5 HOURS AGO
DRUG CLASS: Combination narcotic pain medication with prostaglandin inhibitorREASON WHY PRESCRIBED FOR THIS PATIENT: Postoperative pain relief
TWO MAIN PRECAUTIONS/CONSIDERATIONS FOR THIS PATIENT WITH THIS MEDICATION:1. Prescribed acetaminophen dosage is less than 4 gram/day - OK2. No anti-inflammatory effects - will not affect blood clotting times 3. Watch for respiratory suppression4. Causes constipation
SHOULD IT BE ADMINISTERED AS WRITTEN? NORATIONALE: Clarify dosage with prescriber
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7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
PATIENT PROFILE - Robin RitterInstructor Copy
5
5-MINUTE NURSING CARE PLAN
Problem #1: Impaired tissue perfusion R/T coronary blood vessel blockage AEB patient report of angina pain
Goals: Relief of chest pain within 15 minutes
Interventions:1. Assess quality and severity of chest pain2. Administer nitroglycerin sublingual spray as ordered3. Assess precipitating factors for pain
Evaluation of goal (met/not met):To be done at the end of the shift
5-MINUTE NURSING CARE PLAN
Problem #2: Constipation R/T immobility, narcotic pain medications AEB no BM since before surgery
Goal: BM today
Interventions:1. Obtain order for and administer laxative2. Teach patient to avoid Valsalva maneuver3. Teach patient to increase dietary fiber and fluid intake
Evaluation of goal (met/not met):To be done at the end of the shift
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7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
PATIENT PROFILE - Robin RitterInstructor Copy
MEDICATION ERROR REPORTPatient Name: Physician: Date of Error: / / Time of error: Date of report: / /
Physician Notified? □ Yes □ NoIf Yes: Name: Date: / / Time:If No: Explain:
Nursing Supervisor Notified: □ Yes □ NoIf Yes: Name: Date: / / Time:If No: Explain:
Family/Responsible party notified: □ Yes □ NoIf Yes: Name: Date: / / Time:If No: Explain:
Pharmacy Notified: □ Yes □ NoIf Yes: Name: Date: / / Time:If No: Explain:
Medications Involved:Description of Error (Include medication name, dose, route, and time(s) administered) Care provided and outcome of patient:
Type of Error:□ Wrong drug□ Wrong dose□ Wrong dosage form□ Wrong documentation□ Wrong time□ Wrong route□ Other:
Reason for Error:□ Transcription error□ Misread order□ Miscalculated dose□ Incorrectly measured dose□ Pharmacy error□ Failure to identify patient□ Other:
Actions to prevent recurrence:
Signature / Title: Date:
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7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
ROBIN RITTER
PATIENT PROFILESTUDENT COPY
PATIENT SUMMARY Admitted with Total Hip Replacement (THA) - post-op day #3. Patient has a history of angina and requires sublingual
nitroglycerin. Colace is ordered but no BM since before surgery. Also requires administrationof subQ heparin and clarification of pain medication.
![Page 9: PATIENT PROFILE INSTRUCTOR COPY ROBIN RITTER](https://reader036.vdocuments.site/reader036/viewer/2022071613/6157d524ce5a9d02d46f977f/html5/thumbnails/9.jpg)
7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
PATIENT PROFILE - Robin RitterStudent Copy
1
• Allergies: Plavix, Restoril• 66 year-old admitted with THA
(total hip replacement)• Post-op day #3• Medical history: stable angina• VS: T 99.8 - P 88 - RR 22 - BP
102/64 - pulse ox 91%• Lung sounds diminished bilaterally• No BM since before surgery• Patient just asked for medication to
relieve angina chest pain
Patient Health & History
TODAY’S LAB RESULTSWBC 10.4
RBC 4.8
HGB 7.2
HCT 38.1
PLT 358,000
RBS 66
Na+ 135
Cl- 97
K+ 3.5
![Page 10: PATIENT PROFILE INSTRUCTOR COPY ROBIN RITTER](https://reader036.vdocuments.site/reader036/viewer/2022071613/6157d524ce5a9d02d46f977f/html5/thumbnails/10.jpg)
7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
DAILY PATIENT WORKSHEETRoom
Name
Admitting Diagnosis Doctor
Allergies Admission Date Code Status
Diet Isolation Activity
Medical History Assessment Findings Diagnostic Test
Medications NaClK+CaMgPhosBUN CreatRBSCO2
WBCRBCHGBHCTPLTPTINRPTT
Vitals
TPRBPPOX
Intake Output Skin & Wounds
Pain Last BM Staff RN
PATIENT PROFILE - Robin RitterStudent Copy
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7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
Medication Specifications:
HEPARIN 5,000 UNITS SUBQ BID | Dosage Time: 0900, 1700DRUG CLASS:
REASON WHY PRESCRIBED FOR THIS PATIENT:
TWO MAIN PRECAUTIONS/CONSIDERATIONS FOR THIS PATIENT WITH THIS MEDICATION:
1.
2.
SHOULD IT BE ADMINISTERED AS WRITTEN?
RATIONALE:
COLACE 100 MG PO BID | Dosage Time: 0900, 1700DRUG CLASS:
REASON WHY PRESCRIBED FOR THIS PATIENT:
TWO MAIN PRECAUTIONS/CONSIDERATIONS FOR THIS PATIENT WITH THIS MEDICATION:
1.
2.
SHOULD IT BE ADMINISTERED AS WRITTEN?
RATIONALE:
PATIENT PROFILE - Robin RitterStudent Copy
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7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
NITROGLYCERIN SUBLINGUAL SPRAY - 2 SPRAYS Q 5 MINUTES | Dosage Time: PRN UP TO 3 TIMES PRN CHEST PAIN *LAST DOSE: NOT PREVIOUSLY GIVEN
DRUG CLASS:
REASON WHY PRESCRIBED FOR THIS PATIENT:
TWO MAIN PRECAUTIONS/CONSIDERATIONS FOR THIS PATIENT WITH THIS MEDICATION:
1.
2.
SHOULD IT BE ADMINISTERED AS WRITTEN?
RATIONALE:
PATIENT PROFILE - Robin RitterStudent Copy
4
OXYCODONE 5 MG/ACETAMINOPHEN MG 1 TABLET PO Q | Dosage Time: PRN 4 HOURS PRN PAIN *LAST DOSE: 5 HOURS AGO
DRUG CLASS:
REASON WHY PRESCRIBED FOR THIS PATIENT:
TWO MAIN PRECAUTIONS/CONSIDERATIONS FOR THIS PATIENT WITH THIS MEDICATION:
1.
2.
SHOULD IT BE ADMINISTERED AS WRITTEN?
RATIONALE:
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7013 Orchard Lake Road, Suite 110, West Bloomfield, Michigan 48322Phone: (248) 855-3966 | (877) 593-6011 | Fax: (248) 671-1550
www.DiaMedicalUSA.com | www.SimLabSolutions.com | [email protected]
PATIENT PROFILE - Chris CrawleyInstructor Copy
5-MINUTE NURSING CARE PLAN
Problem #1:
Goal:
Interventions:
1.
2.
3.
Evaluation of Goal (met/not met):
5-MINUTE NURSING CARE PLAN
Problem #2:
Goal:
Interventions:
1.
2.
3.
Evaluation of Goal (met/not met):
PATIENT PROFILE - Robin RitterStudent Copy
5