Concept explainers
To discuss:
The essential information that should be documented in the patient’s electronic record to support safe patient care.
Case summary:
Mr. L is a 52-year-old male patient who has been diagnosed with diabetes and circulatory problems. He had recently undergone an abdominal surgery and admitted in the critical care unit. The site of the surgical wound is found to be moist and the dressing is secured by a tape. During his stay in the critical care unit, his level of consciousness is low and he moderately responds to touch. Further assessment reveals that Mr. L is developing a pressure ulcer and his caregiver has less concern for him.
To discuss:
Any other information that is documented in the electronic health record based on the student nurse’s assessment and interventions.
Case summary:
Mr. L is a 52-year-old male patient who has been diagnosed with diabetes and circulatory problems. He had recently undergone an abdominal surgery and admitted in the critical care unit. The site of the surgical wound is found to be moist and the dressing is secured by a tape. During his stay in the critical care unit, his level of consciousness is low and he moderately responds to touch. Further assessment reveals that Mr. L is developing a pressure ulcer and his caregiver has less concern for him.
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CP4 AC FUNDAMENTALS OF NURSING 12 MONTH
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