Preoperative Phase The First Interaction I Had With My Assigned Patient

It is no secret that the medical profession deals with some of population’s most valuable records; their health information. Not so long ago there was only one method of keeping medical records and this was utilizing paper charts. These charts, although still used in many practices today, have slowly been replaced by a more advanced method; electronic medical records or EMR’s. “The manner in which information is currently employed in healthcare is highly inefficient, which slows down communication and can, as a result, reduce the emergence and

This assignment will reflect on the effectiveness of my clinical and interpersonal skills in relation to my position as a nurse in a busy critical care unit. It will primarily focus on one particular patient and the care they received by myself in their immediate post operative period. In accordance with the NMC’s code of professional conduct names will not be used to protect the patient’s confidentiality. NMC (2008).

* Pre-Op Nurse: The pre-op nurse is the second person in the process to interact with the patient and their family. The pre-op nurse is responsible for all pre-surgical workups for the patient. This includes medical and family related activities. The pre-op nurse communicates with the family the specific expectations for the patient’s surgery and associated timeframes.

The preoperative phase begins when the patient is scheduled for surgery. The role of the perioperative nurse is to first determine any risks the patient may

VASNHS Surgical Specialty Outpatient department has a designated pre-operative management unit that oversees the patients undergoing surgery. The predicaments stem from various guidelines or protocol originating from numerous surgeons and clinics. At present, the pre-operative nurses abide simple pre-op instructions (NPO protocol, medications, what to bring, during the surgery, transportation, cancellation instructions) for the entire Surgical Specialty Outpatient department. Surgical procedures are being canceled due to lack of communications and cancelations of patients prior to surgery date.

On my second day of clinical experience this week I focused a lot on time management and documentation for a full patient load, and also on the admission and discharge process. After taking report on all three of our patients, I began my initial morning assessments. It was clear that our 8-year-old post-operative appendectomy was ready to be discharged. My priorities were assessing her incision sites and ensuring the presence of bowel sounds, as well as making sure she did not have a fever and was tolerating a general diet. After completing my assessment and documenting in the computer, we

She called patients who were discharged from the hospital after surgery to follow-up with their recovery. She asked each of them about their pain control, if they have had a bowel movement, and if they were taking aspirin. Direction was given if there was concern in any of these categories or other questions that arose during the conversation. The information specific to the above categories was then documented in several locations where it is tracked for quality purposes. The idea is the patient is receiving accurate discharge instructions and medication reconciliation before leaving the hospital. Laura tracks this and follows up with staff and the physicians if there are

Patient’s information is kept confidential and less likely to have a breach the HIPPA law. Having regular charting system, things can easily get lost. Pages can come out of the chart without knowing really knowing or noticing; personnel’s handwriting may not be legible, which cause confusing for other staff and billing, and the list can go on. With the electronic medical records, the need for paper would be less.

Today’s healthcare is changing, and more hospitals are commencing to go paperless using computers for both medical records and charting. Computers are widely accepted, in personal and professional settings. It is an essential requirement for computer literacy. Numerous advances in technology during the past decade require that nurses not only be knowledgeable in nursing skills but also to become educated in computer technology. While electronic medical records (EMR’s) and charting can be an effective time management tool, some questions have been asked on how exactly this will impact the role and process of nursing, and the ultimate effects on patient safety and confidentiality. In order to

The purpose of this journal is to reflect on my experience and skills gained during my clinical placement at Ben Taub Hospital. On my first clinical day, I was excited and nervous at the same time. My first placement was in the PREOP/PACU area. I was assigned to help a patient who had been in the PACU area going on 2 days. Normally, once the patient comes from surgery they are only in the PACU area for a short period of time before they are discharged home or given a bed in another area of the hospital. This particular patient still had not received an assignment for a bed. The physicians would make their rounds to come check on him daily. The patient was a 28-year-old Hispanic male, non-English speaking, he had a hemicolectomy. He had a NG tube, urinary Foley catheter, and a wound vac. My preceptor had just clocked in and she needed to check on the patient’s vitals and notes from the previous nurse. Once she introduced me to the patient and explained while I was there, she then asked me to check his vitals. (Vital signs indicate the body’s ability to regulate body temperature, maintain blood flow, and oxygenate body tissues. Vital signs are important indicators of a client’s overall health status (Hogan, 2014). I froze for a quick second. I have practiced taking vitals numerous of times and I knew I could do it correctly. I started with the temperature first, when I was quickly corrected on a major mistake I had made by my preceptor. I HAD FORGOT TO WASH MY HANDS and PUT

Communication is the key to relating in all environments. When communication lines are broken, it makes take in jobs and personal relationship suffer. In medical environment communication is key in running hospital, nursing home and community care providers. With technology our communication has advanced because now we have electronic medical records. Electronic medical records are a way of providing the medical staff and insurance on the patient health information and insurance coverage. As stated by About.com, “This also provide the doctors away to for individual patients, access to good care becomes easier and safer when

A surgical nurse is responsible for monitoring and ensuring quality healthcare for a patient following surgery. Assessment, diagnosis, planning, intervention, and outcome evaluation are inherent in the post operative nurse’s role with the aim of a successful recovery for the patient. The appropriate provision of care is integral for prevention of complications that can arise from the anaesthesia or the surgical procedure. Whilst complications are common at least half of all complications are preventable (Haynes et al., 2009). The foundations of Mrs Hilton’s nursing plan are to ensure that any post surgery complications are circumvented. My role as Mrs Hilton’s surgical nurse will involve coupling my knowledge and the professional

246). Twenty-two participants spoke of the provision of information giving as comprehensive and helpful in surgical preparation, in contrast eight participants felt the information giving was deficient in its content. One individual went on to say “I personally felt that I was not given any information once the preassessemnt nurse discovered I worked as a staff nurse on a day surgery unit in another hospital” (Gilmartin, 2003, p. 247). Negative case studies do not weaken research findings but make the study more credible as the researcher has considered alternative views in the analysis of data (Tappen, 2011).

The set up was similar to my clinical routine. On entering the room, my teammates and I greeted her and asked her how she was doing. She was alert and oriented. She sounded exhausted. She was having generalized pain. I asked her if she was feeling short of breath she said “no.” She was already on 3L of oxygen through nasal cannula with an oxygen saturation of 93%. Her skin was warm to touch and her pulse bounding. She had crackles throughout her lung field. During my clinicals, I learned to link my patient’s assessment findings to her labs and orders. I also practiced using the SBAR to contact the physician. I attended an interdisciplinary round at the oncology unit where the team was planning palliative care for a patient. I noticed that the team was more directed towards pain management and therapeutic interventions. The team also made sure to include the family and the patient in the care. During the simulation, we contacted the doctor for an order of morphine.

The nurse was very knowledge about the delivery of care following coronary artery bypass grafts. She was able to explain the importance of dressing cares, assuring the chest tube