Exam 4 Study Guide
1 Discuss in general which assessment findings would alert you to the need for immediate intervention. (When you notify a physician immediately, or call the rapid response team).
You notify the physician or rapid response team in early clinical changes in condition that occur in most patients for up to 48 hours before a code blue. Therefore observe for, document, and communicate early indicators of patient decline, including decreasing blood pressure, increasing heart rate, decreased respirations, and changes in mental status.
2 Differentiate assessment findings that only require documentation versus those findings that need to be relayed to the health care team (i.e. normal findings).
Anything abnormal needs to be reported to the doctor. These findings need to be documented as well. Document allergies according to facility policy. Accurate measuring and recording of height and weight are important for proper dosage of anesthetic agents. Ensure that the results of all laboratory, radiographic, and diagnostic tests on the chart. Document any abnormal results, and report them to the surgeon and the anesthesia provider. If the pt. is an autologous blood donor or has had directed blood donations made, those special slips must be included in the chart. Record a current set of vital signs within 1 to 2 hours of the scheduled surgery time, and document any significant physical or psychosocial observations. Report special needs concerns, and instructions (advance directives) to the surgical team, as required by The Joint Commission’s NPSGs. For example, advise the surgical team if the pt. is a member of Jehovah’s witnesses and does not accept blood products or if the patient is hard of hearing and does not have his or her hearing aid. This information assists the surgical team in providing continuity of care while the pt. is in the surgical area.
3 Prioritize which patient to see first when given a report on multiple patients.
First level patient - these
You notify the physician or rapid response team in early clinical changes in condition that occur in most patients for up to 48 hours before a code blue. Therefore observe for, document, and communicate early indicators of patient decline, including decreasing blood pressure, increasing heart rate, decreased respirations, and changes in mental status.
2 Differentiate assessment findings that only require documentation versus those findings that need to be relayed to the health care team (i.e. normal findings).
Anything abnormal needs to be reported to the doctor. These findings need to be documented as well. Document allergies according to facility policy. Accurate measuring and recording of height and weight are important for proper dosage of anesthetic agents. Ensure that the results of all laboratory, radiographic, and diagnostic tests on the chart. Document any abnormal results, and report them to the surgeon and the anesthesia provider. If the pt. is an autologous blood donor or has had directed blood donations made, those special slips must be included in the chart. Record a current set of vital signs within 1 to 2 hours of the scheduled surgery time, and document any significant physical or psychosocial observations. Report special needs concerns, and instructions (advance directives) to the surgical team, as required by The Joint Commission’s NPSGs. For example, advise the surgical team if the pt. is a member of Jehovah’s witnesses and does not accept blood products or if the patient is hard of hearing and does not have his or her hearing aid. This information assists the surgical team in providing continuity of care while the pt. is in the surgical area.
3 Prioritize which patient to see first when given a report on multiple patients.
First level patient - these