Tracer Patient summary:
A 67year old female patient was scheduled for a laparoscopic hysterectomy. However 5 weeks prior to hospitalization she was hospitalized and the case was converted to an open procedure due to excessive bleeding. After being discharged she developed fever and drainage and was readmitted again for possible postoperative infection seven days ago. On day two of admission she underwent surgery for post operative abscess and insertion for a central line for long-term antibiotics. She is scheduled to go home with home health providing oversight of antibiotic therapy.
In order to be compliant with Joint Commission standards for Record of care, Treatment and services an assessment was done which is outlined below.
The admission assessment is the fundamental baseline assessment which begins the process of assessment, diagnosis, planning, intervention, and evaluation. This assessment is a critical first step in the patient’s care and serves as the first complete introduction the nurse has to the patient. During this process, the nurse assesses the patient from head to toe and establishes a baseline assessment. This provides a point of reference for other nurses to compare against to see if the patient’s condition is improving or declining. The history and physical also points out problem areas to the nurse, which allows him or her to write a care plan that will guide the nursing staff in their care of the patient. For example, a patient may be admitted for excessive uterine bleeding, but during the assessment the nurse notes that the patient has experienced significant weight loss and is at risk for skin breakdown because she has poor skin turgor, and is immobile and incontinent. The nurse would write a care plan on the bleeding as it relates to, additionally, the nurse could write a care plan on the patient’s risk for skin breakdown and nursing interventions to reduce the patient’s risk for developing a decubitus...