This system is used for reporting observed and new ADEs at the VA (VA, 2014). VA ADERS allows individuals to report, track, and electronically submit serious adverse drug events to the FDA’s MedWatch system (VA, 2014). Nurses should be educated on new medication policy and procedure, as well as, protocols (Anderson & Townsend,
We also helped nurses in each floor if they had any questions about how to handle a patient with pressure ulcers. We also did many in services with new products to treat and prevent pressure ulcers. We monitored the pressure ulcers if they were community, hospital, or unit acquired and then, the manager of the Wound Care Program had to send all this information quarterly to the NDNQI, and if we found many patients with newly hospital acquired pressure ulcers the Wound Care Program manager and her team had to implement a plan with new ideas to lower the pressure ulcers in the floors, and to educate the nurses and techs in order to be more successful in prevention of pressure ulcers because the treatment can be
I rounded daily with every department (ICU, MSU, PNU, L&D, BHU) and met every patient. I would receive report from each department Charge Nurse and CNS (who was also novice). I spot checked documentation in the Essentris computerized charting and randomly would check on drug administration. I was involved with disease and discharge management and followed up on all referral consults and processes. I would meet with every CNS quarterly and work on their clinical challenges and also what Process Improvement Projects they were currently working on.
The fact is we want to get sick people better; it is in a nurse’s nature to care for the well-being of each patient. We study for hours in nursing school to be the best nurses we can be so that we can learn to properly assess and provide treatment. What every nurse must always remember is that patients have rights. It is important to get a patients informed consent and to be sure that they understand the procedure they are about to undergo, why they need the treatment, the risks involved, and the ramifications behind the decision to give their consent. When a patient does not fully comprehend a procedure, how can we as nurses expect them to readily agree to medical interventions blindly?
Ultrasound technicians may work and consult with everyone from janitors and other medical staff to medical assistants, nurses, physicians and radiologists. A medical assistant, or the ultrasound tech them self will call the patient back, escort them to a changing room and instruct them on how to be ready, or how to wear a gown for the procedure. The medical assistant will guarantee all pre-exam procedures have been followed correctly. After ensuring the patient is ready for the exam, the medical assistant would then report to the sonographer that patient is ready. Nurses also work closely with ultrasound technicians and patients.
I will be assigned to a new patient next week, and I will make sure that I will know everything about all the medications the patient takes. That will be done in order to know what I am going to be administering and how dangerous it will be if any of them are administered incorrectly. I will make sure all preventable complications will not occur. In order to do that, I need to know the function of the medication and what they are really for based on the patient’s diagnoses.
Tuesday, March 29th, 2016: Montana State Hospital The day began with a care conference by an interdisciplinary team (psychologists, social worker, nurses, and psych techs). Every patient on the wing was discussed about their current situation, behavioral problems, or change in care plan. The nursing process seemed to be utilized when dealing with these problems. The problem was assessed by the entire team, the root cause was determined, a plan was established to implement, and then would be evaluated the next day. Following the care conference, we observed an intake of a new patient.
Then utilizing the results the clinic can drill down to the patients receiving beta-blockers, diabetes (eye & kidney exam) to determine if the correct interventions were being provided by the health care physician and identify gaps in treatment and then ensure the physician receives reminders on preventable measures to close quality care gaps and improve the quality of care provided to patients (Eddy, Pawlson, Schaff, Peskin, Shcheprov, Dziuba & Eng, 2008). I completed a chart audit of over 200 med advantage patient records this week utilizing CPT codes,ICD-9, progress notes, and lab results for HEDIS measures for HgbA1c (9 every 3 months), Diabetic Eye Exams (yearly), Colonoscopy Exam (every 10 years-unless indicated otherwise), Mammograms (yearly after age 50), BP (controlled < 100), and medication adherence (beta blockers, ACE/ARB, cholesterol, diabetic, etc) and my findings would be reported to BCBS, Humana, Clear River, Health Springs and NCQA. The yearly eye diabetic eye exam can detect retinopathy and help ensure early treatment to prevent blindness, control of BP can reduce MI infraction while yearly colonoscopy and mammograms can detect early signs of cancer and HbbA1c can help detect and identify gaps in diabetes
As always, the very first step of Nursing care begins when we enter the patient’s room for assessment. The way we introduce ourselves or talk to patients the first time determines the way the entire relationship will unfold. That speaks volumes when it comes to Nurse-patient relationship. Nurse assesses patient’s and his or her own understanding of what is happening Gorman (2008). I do realize that the more we interact with patients, keep our differences or problems behind us, the more the patient becomes more open to discussion about patients’ needs and wants.