patient care plan solution

Understanding Health Insurance: A Guide to Billing and Reimbursement
14th Edition
ISBN:9781337679480
Author:GREEN
Publisher:GREEN
Chapter8: Hcpcs Level Ii Coding
Section: Chapter Questions
Problem 7R
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Question
I need a patient care plan solution
2
vital signs
monitor vital signs
cal assessment
ite
Group 2
Names:
cations
er medications - 6 rights
medications to patient
finding to
findings to physician (SBAR)
Owash hands
Dintroduce self
Provide privacy
Ba
Didentify patient
Dobtain initial vi
Evaluate & m
Perform phys
Perform
DAssess IV site
Administer n
DExplain med
Report find
e orders and read back to verify
ment physician's orders
Jate urine output (if neede
Cain lab/specimen (if needed)
plain lab data (if needed)
xplain lab values to patient
Receive or
100/30 Group 3
ally pt/family
Communicate therapeutically pt
Reinford
einforce Pt and family education
Prioritize interventions
Demonstrate teamwork
Comment
& follow up as needed
Re-assess & fo
Communicate findings to nurse/team Do
Dimplemen
DEvaluate
Obtain
DExplais
DExpla
Re-F
Simulation Basic Skills
go.ml / 30 minute
palpitations, swollen feet and legs, weight gain and complains of difficulty sleeping at night. Use your
65-year-old patient Valarie Voss is admitted on your unit with severe chest pain, shortness of breath
Scenario 6- Role Players: Primary Nurse, Secondary Nurse, Medication Nurse
nursing judgment and skills to care for the client. Perform the following:
60
8.8 U
G
may 66 d
vve
IV fluids: Normal Saline run at 85cc/hr
S 1.38
1. Interview the client for history and background of the illness
Nursing Interventions
2. Perform a focused physical assessment
Physician Orders
Admit to medical unit
2. Vital signs: VS q 4 hours
4. Oxygen 2 Liters via nasal canula
5. Weigh patient daily
1.
3.
6. Labs-CBC, Basic metabolic panel
7. Chest X-ray
0.9
BUN 6.0
Crea
time
Nitroglycerin 0.4mg sublingual q 15 minutes x 3 doses
Administer medications
al signs
nitor vent
vital signs
cal
Aspirin 81mg 1 tab PO q daily
Morphine 1mg IM q 4 hours PRN
Metoprolol 25mg Po q daily
edications - 6 rights
ications to patient
dings to physician (SBAR)
ders and read back to
t physician's orders
at phy
urine output (if needed)
ab/specimen (if needed)
Mab data (if needed)
Slab values to patient
Sess & follow up as needed
te findings to nurse/team
Chunicate t
municate therapeutically pt/family
force Pt and family education
Coritize interventions
emonstrate teamwork
Snment:
CUT HERE for Instructor Po
Lab
o verify
ver
ghts
n
JUST
ack to verif
ders
needed)
needed)
ded)
atient
as nee
gs to n
peuti
mily
ion
Transcribed Image Text:2 vital signs monitor vital signs cal assessment ite Group 2 Names: cations er medications - 6 rights medications to patient finding to findings to physician (SBAR) Owash hands Dintroduce self Provide privacy Ba Didentify patient Dobtain initial vi Evaluate & m Perform phys Perform DAssess IV site Administer n DExplain med Report find e orders and read back to verify ment physician's orders Jate urine output (if neede Cain lab/specimen (if needed) plain lab data (if needed) xplain lab values to patient Receive or 100/30 Group 3 ally pt/family Communicate therapeutically pt Reinford einforce Pt and family education Prioritize interventions Demonstrate teamwork Comment & follow up as needed Re-assess & fo Communicate findings to nurse/team Do Dimplemen DEvaluate Obtain DExplais DExpla Re-F Simulation Basic Skills go.ml / 30 minute palpitations, swollen feet and legs, weight gain and complains of difficulty sleeping at night. Use your 65-year-old patient Valarie Voss is admitted on your unit with severe chest pain, shortness of breath Scenario 6- Role Players: Primary Nurse, Secondary Nurse, Medication Nurse nursing judgment and skills to care for the client. Perform the following: 60 8.8 U G may 66 d vve IV fluids: Normal Saline run at 85cc/hr S 1.38 1. Interview the client for history and background of the illness Nursing Interventions 2. Perform a focused physical assessment Physician Orders Admit to medical unit 2. Vital signs: VS q 4 hours 4. Oxygen 2 Liters via nasal canula 5. Weigh patient daily 1. 3. 6. Labs-CBC, Basic metabolic panel 7. Chest X-ray 0.9 BUN 6.0 Crea time Nitroglycerin 0.4mg sublingual q 15 minutes x 3 doses Administer medications al signs nitor vent vital signs cal Aspirin 81mg 1 tab PO q daily Morphine 1mg IM q 4 hours PRN Metoprolol 25mg Po q daily edications - 6 rights ications to patient dings to physician (SBAR) ders and read back to t physician's orders at phy urine output (if needed) ab/specimen (if needed) Mab data (if needed) Slab values to patient Sess & follow up as needed te findings to nurse/team Chunicate t municate therapeutically pt/family force Pt and family education Coritize interventions emonstrate teamwork Snment: CUT HERE for Instructor Po Lab o verify ver ghts n JUST ack to verif ders needed) needed) ded) atient as nee gs to n peuti mily ion
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