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services include immunizing children, teaching pg women, treating
infections and illnesses, referring for dx and tx of STI's and providing
information about maintaining health.
Services provided: administering medications, conducting routine health screenings, maintaining immunization records
nameagephysicians in charge of ptadmitting diagnosisvital signs - O2
and L/minintakes and outputs (I/O's)neurological statusIVF (intravenous
fluids)IV site/assessmentTubes and drainssurgical procedure completed or
scheduledcurrent
conditionmanifestationsallergiesmedicationstreatmentslab dataany
equipment that is needed for caresnursing care priorities are
identifiedexistence of advance directives
document and have a witness back you up that they are leaving against advice.
Hospital admissions and lengths of hospital stay have decreased.
Increasing numbers of pts are having surgery, diagnostic tests, and
emergency care in ambulatory care settings or on a hospital outpatient
basis.
family will often be the ones that provide the largest amount of the
cares that the pt will need after discharge. They will need to know:how
to change sterile dressingsadminister tube feedingsmonitor IV
medicationsprepare special dietsgive complete physical careThe NURSE
must ensure that family members are taught the necessary knowledge and
skills that will be needed.
providing end of life/palliative care. Supportive services include
providing physical, psychological, social, and spiritual care for the
dying persons, their families, and other loved ones. Interdisciplinary
team includes chaplain, therapists, social workers, volunteers,
counselors, nurses.
Medicare-DRG's >65 years old, payment plan based on patient
classification categories called DRG's (diagnosis related groups) The
plan pays the hospital a fixed amount that is predetermined by the
medical diagnosis or specific procedure rather than by the actual cost
of hospitalization and care.
assessing the strengths and limitations of the patientthe family or
support personthe environmentimplementing and coordinating the plan of
care (what other services or resources will the pt need to be taken care
of; home health, hospital beds, etc
Case management services help individuals learn about and gain access
to any services that can help address their needs. These include, but
are not limited to, Medicaid wavier and Medicaid State Plan services as
well as medical, social, educational, county and municipal services.
Episodic, hospital care setting only.The process of coordination an
individuals healthcare foe the purpose od maximizing positive outcomes
and containing costs.
Send only a COPY of charts, the original chart stays with your facility
Use of suppliesNursing care/ delegationCritical/clinical pathwaysCase management
Episodic, hospital setting only
Responsibilities might include conducting physical examinations and suturing lacerations.
trained in techniques that improve pulmonary function and oxygenation.
May administer testing that measures lung function, and educating the
patient.
Assessment Inventory of pt personal itemsmedication reconciliation
(checked and filled out again with each transfer and on discharge.
Critical pathways, also known as critical paths, clinical pathways, or
care paths, are management plans that display goals for patients and
provide the sequence and timing of actions necessary to achieve these
goals with optimal efficiency.
services that provide for the patient who is not hospitalized
overnight but who requires diagnosis or treatment, care, and education
on an outpatient basis. Such as surgical procedures, diagnostic tests,
medications, physical therapy, counseling, and health education.
Care provided by caregivers of homebound ill, disabled, or elderly
patients. Gives the primary caregiver some time away from the
responsibilities of day to day care.
Restore function or prevent further disability:massageheat
coldwatersonar wavesexerciseselectrical stimulationwalkingfocus is on
the waist down
Care centers and clinics that may be located in hospitals. May be
located in malls and offer walk in services so that appointments aren't
necessary. Urgent care services. You can just WALK (AMBULATE) right in.
Fragmentation of care can lead to a loss of continuity of care
resulting in conflicting plans of care, too much or too little
medication, and higher healthcare costs.
day caresmental health centersschoolsindustryhomeless sheltersrehabilitation centers
Medicaid: Plan that includes anybody of any age that is low income.
services that provide for the patient that stays overnight for an indeterminate time.
Transitional sub acute careassisted living facilitieslong term care nursing homesretirement centers residential institutions
Assists patients to adapt to limitations. Use adaptive devices and
strategies to aid pts in carrying out the activities of daily living.
Focus is mainly on upper body.
ORIGINAL chart and Kardex are moved to the new unit. Other depts. need
to be made aware of the move. Nurse in original area gives a verbal
report about the pt to the nurse in the new areaNotify family and other
therapiesSend original chart
SBARSituationBackgroundAssessmentRecommendations
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