Activity to be Audited 5.4.3 Request Form Information: a) Does the request form contain: I. Forename and surname II. Gender III. Date of birth IV. Address V. Hospital number b) Name or other unique identifier of clinician or other person legally authorized to request examinations & Destination of report: c) Type of primary sample and the anatomic site of origin, where appropriate; d) Examinations requested; e) Clinical information relevant to the patient, which should include gender and date of birth, as a minimum, for interpretation purposes; f) Date and time of primary sample collection; g) Date and time of receipt of sample by the laboratory.
1. Discuss the age specific physical assessment/s properly completed this week. State techniques you used in completing the physical assessment of your patient. Often these techniques will differ from an examination of an adult. * B. was an 16 year old male.
Furthermore, there are two vital sign changes that I, as a Certified Nursing Assistant, should be aware of. If a patient’s respirations and or pulse are thready and shallow, a nurse should be notified immediately. This could mean that oxygen saturation is being compromised, and
Postoperatively, the vascular surgeon refers these patients to physical therapy for early ambulation training. As a physical therapist, thorough physical assessment including vital signs is necessary; especially blood pressure determination to assure that the bypass graft is getting enough perfusion. Low BP reading can result in low blood flow to the graft site; conversely, high BP can damage the graft due to elevated pressure. Equally important, assessing the skin color, temperature and the pulse of the surgical limb by using a Doppler ultrasound and report findings to the bedside nurse
The client is a fairly active 21 year old with no chronic illnesses other than a diagnosis of arthritis as a child. He is 6 feet tall (72 inches) and weighs 216.4 pounds (98.2 kg). His BMI is 29.3, which puts him in the overweight category. The client has an extensive list of chronic diseases found in his family history. His paternal grandfather died of leukemia, but prior to that had won battles against lung cancer and colon cancer, maternal grandmother died of a brain tumor, paternal grandfather died of a heart attack, and both parents have been diagnosed with type 2 diabetes.
A complete assessment is not necessarily carried out each time. A comprehensive assessment is part of a health screening examination. According to Zambas (2010), physical assessment is taking an educated, systematic look at all aspects of an individual’s health status utilizing knowledge, skills, and tools of health history and physical exam. Patient physical assessment is one of the most important nursing interventions. This is the moment a nurse would be able to identify all the negative issues, to collect the data (objective and subjective).
(Marieb and Hoehn, 2016) In my clinical setting, it was expected that a level of proffesional protocol is carried out for a correct, and safe arterial reading while maintaining a hygienic and aseptic approach that is safe, and reduces the risk of detrimental harm to myself as a healthcare professional and to the patient in my care. Bp is read from patients as a matter of determining illness by monitoring what is known as a NEWS score, presenting a validating number to recognise the level of health of an individual. (Royal College of Nursing, 2015) Hypertension, high blood pressure, or hypotension, low blood pressure, can be a sign of a decreased state of health for my patients, therefore it was imperative that a bp exam is carried out in the correct way for the
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Towards the end of the procedure the nurse counted all sponges and needles with the scrub to make sure that no equipment was left within the patient. The nurse also continued to document information such as the length of the surgery and the amount of blood lost throughout the procedure. Lastly, the circulating nurse cleaned the room and then transferred the patient into a hospital bed to be transferred to the post-anesthesia care unit. Ignatavicius and workman (2013) addressed that these are all responsibilities of the circulating nurse (p.