I was able to use the EHR information system to coordinate care of my patients by viewing patient information, such as their diagnosis, health history, surgical history, up-to-date medication and allergy lists, laboratory values and plan of care.
2. Were you able to acknowledge orders with your staff nurse?
Yes, I was able to acknowledge patients order such as diet changes, physical therapy consult and medication changes. I processed the orders too.
3. Were you able to check the work list throughout your shift to complete the care of your patient with your staff nurse?
Yes, I was able to check the work list throughout the shift to complete the care of the patient. Examples include checking the worklist to find if there is an order to collect blood sample to the laboratory for investigation or to take the patient to get an MRI.
4. Were all meds given on schedule when you checked for “overdue meds”?
Yes, all medication was given on the schedule when I checked for overdue meds because the HER information system prompts me by highlighting the task in red or yellow, signifying either it time for medication, abnormal laboratory value or a new order to acknowledge.
5. Were you able to teach patient about their condition from the identified education plan? Work with patient classification system.
Yes, I taught my patient that Laxis is a diuretic and so he will be voiding frequently. I also taught him the side effect of laxis such ototoxicity, so if he feels any ringing in his ears he should report it to me. I taught my other patient the importance of lying flat in bed to prevent bleeding from site of Art line insertion. I taugh...
... middle of paper ...
...ritical lab value and intervention taken on your shift:
Patient had no critical or abnormal laboratory value, all his laboratory values were within the normal range. The intervention that I did for the patient, was to manage is pain by administering his pain medication as schedule to get him to relax.
21. Student will reflect on their own thoughts and ideas with each objective weekly to support how they would improve policy or quality of care:
I had a wonderful clinical experience this week. Although very tiring, I was able to manage the care of two patient on both Wednesday and Thursday effectively whiles my preceptors observe. I was able to delegate task to for the first time and actually track the progress of the task as completed by the UAP on the unit. It was a strange feeling but yet exciting to know I am getting to the level of being in charge and delegating.
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