You need to be an anesthetist. You talk very little to the patient or family & then they are unconscious. Most I know also don't talk to the staff a lot. Stay out of surgery or ICU. The patient...
We were having this discussion this morning about how to co-sign in the EMR/BCMA for medications such as IV pain medications, IV heparin, insulin, TPN, chemo & so forth. Our current record only...
I ask "are you having any pain?" or "what is your pain level?" I also encourage the alternative measures such as repositioning, warm pack, cold pack, ambulation, etc. Remember though, a patient's pain...
Aspiration Pneumoniae could develop in 24hrs. Whether it was due to the water/meds or the feeding would require sputum samples & possibly a bronche. Continue to follow aspiration prevention...
Pediatricjo replied to Pediatricjo's topic in Pediatric
Our policy states "All patients will have a complete assesment done at the beginning of every shift; the nurse will document any changes from the baseline assessment (admission). Assessment of body...
The question has come on our unit what is proper: a documented full assessment or an assessment charted by exception. Currently we document a full assessment every shift. One of our nurses floated to...
Pediatricjo replied to Pediatricjo's topic in General Nursing
Just an update. The committee met again and the proposer was there to explain that it does not have to be each abnormal lab value. One could click the item to say they notified the physician of...
Pediatricjo replied to anon456's topic in Pediatric
We have some "special" patients over the age of 18 that the pediatricians have aged out for us. There is a Pediatrician shortage in our town & they need the space in their practice. However, we...
Pediatricjo replied to KelRN215's topic in Pediatric
ChristineN, I never thought of that. I just took it for granted. We leave ours indefinitely for the above stated reasons. When we did Outpatient Infusion therapy on our Pedi unit we didn't have...
Pediatricjo replied to Pediatricjo's topic in General Nursing
We have a critical value note for those items. In this we either notify the doctor & what was done or we didn't & why we didn't. It's all electronic charting so it's point-&-click. THis is...
Does any other facility require you to enter non-critical values into the nurse's note? We have now placed a section in the nurse's note for entering abnormal lab values, did you call the doctor &...
You can use the same things. Post an idea pad on the wall to let them write ideas. Still look at what they seem to have trouble with or what the doctor's say. When approaching summer or winter have...