Nursing Case Study

1. This week how you were able to use the EPIC/ EHR information system to coordinate patient care delivery.

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

It was not difficult but time consuming. There was enough nurses for the patient acuity, and one nurse was send to the E/R to help. The charge nurse informed me that, she is able to assign the patient based on her experience with working with the staff. She know which nurse can take two high risk patients and the one that can handle only one high risk and low risk. She also states that, the staff help each other by rotating patient care if the nurse is overwhelm by the patient to help release stress and optimize quality patient

16. Medications (Generic and trade name) and the reason why patient is taking. Please identify the route of the medication given:

CARVIDILOL (Coreg) 25mg tab, PO Daily with meals. To decrease patient blood pressure.

LOSARTAN (Cozaar) 50mg tab, PO Daily. To decrease patient blood pressure.

CIPROFLOXACIN (Cipro) 400mg in 1200 IVP over 2hour, three times daily. To treat the patient of suspected pneumonia infection.

17. Student will identify abnormal/Critical lab value and intervention taken on your shift:

i. Hematocrit: 26.3 Low Normal Range: 42- 52% ii. Hemoglobin: 8.5 Low Normal Range: 14- 18g/ dL iii. BUN: 6.4 Low Normal Range: 10- 20mg/dL

Patient has history of kidney disease, which put the patient at risk for anemia and fluid overload. I called the physician to request an order for a diuretic per my preceptor order to help relive patient of the fluid overload.

18. PATIENT TWO:

Name: F. K

Patient Diagnosis: pneumonia

Surgical Procedure: Patient has history of CHF, Hypertension, A filb, COPD, MI and high