What did the nurse learn about the 82-year-old's heart failure?
D While admitting an 82-yr-old patient with acute decompensated heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." When planning for the patient's discharge the nurse will facilitate a
What is the correct nursing diagnosis for a 78-year-old with chronic heart failure?
During a visit to a 78-yr-old patient with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of "feeling too tired to get out of bed." Based on these data, a correct nursing diagnosis for the patient is a. activity intolerance related to fatigue.
Which physical findings are characteristic of acute decompensated heart failure (ADHF)?
A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. Several drugs have been ordered for the patient.
How should a nurse plan discharge teaching for a heart failure patient?
The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide. Appropriate instructions for the patient include a. limit dietary sources of potassium. b. take the hydrochlorothiazide before bedtime. c. notify the health care provider if nausea develops.
Which patient should the nurse assess first after receiving change-of-shift report?
The nurse has received the shift report. Which client should the nurse assess first? Assess the client for abnormal bleeding.
What should be included in a change-of-shift report?
It should include the patient's medical history, current medication, allergies, pain levels and pain management plan, and discharge instructions. Providing these sorts of details about your patient in your end of shift report decreases the risk of an oncoming nurse putting the patient in danger.
What would be included in a shift assessment?
Shift assessment includes airway, breathing and circulation. Airway assessment usually assesses on patient secretion, artificial airway, noise and cough. Air entry and movement, oxygen requirement, work of breathing, ventilator dependent and breath sound usually assess in breathing assessment.
What do nurses do at shift change?
Traditionally, nurses going off duty typically talk with the nurse coming on for the next shift in a hallway or at the nursing station, giving information on their patients' status and needs, according to the report. Other times nurses communicate for the next shift via a written report. 2.
What are the four priorities identified in the change-of-shift report?
Experts offer one or several of the four Ps — purpose, picture, plan, and part — as a model for clarity in life, which can be adapted for focusing shift report on the essential and most effective components.
Why is change-of-shift report important?
The importance of a change-of-shift report can't be underestimated. Not only does the report provide nurses with an effective and meaningful way to transfer responsibility and accountability of patient care, it helps build team cohesion, enhances shared values, and supports ritualistic functions.
Which assessment should the nurse complete first?
Head-to-Toe Assessment Sequence “During an assessment, the first thing that should be noted is the patient's overall appearance or general status,” Zucchero says. “This includes level of alertness, state of health/comfort/distress, and respiratory rate. This is done even prior to taking vital signs.”
What is priority assessment?
Priority Assessment means an evaluation of the potential risk for a food-borne illness to occur in a food service facility using a given set of parameters as established by the Department in Regulation .
What are the four types of patient assessment?
There are mainly four types of health assessments – Initial Assessment, Focused Assessment, Time-lapsed Assessment, and Emergency Assessment.
What is one responsibility of a shift charge nurse?
Coordinating daily administrative duties, including schedules, nursing assignments and patient care. Recording patients' medical records and monitoring vital signs. Supervising nursing staff and overseeing their needs.
What are the 5 P's of patient handoff?
The Sentara health care organization adopted behavior-based expectations to improve the handoff process and used tools including the five Ps (patient/project, plan, purpose, problems, and precautions). It reported a 21-percent increase in effective handoffs.
How do bedside shift change reports improve care?
The benefits of bedside reporting are numerous and include increased patient involvement and understanding of care, decreased patient and family anxiety, decreased feelings of “abandonment” at shift changes, increased accountability of nurses, increased teamwork and relationships among nurses, and decreased potential ...
What should be included in the change control activities?
The five steps of a change control processChange request initiation. In the initiation phase of the change control process, a change is requested. ... Change request assessment. ... Change request analysis. ... Change request implementation. ... Change request closure.
What should be included in a change plan?
How to Write a Change Management PlanDemonstrate the reasons for the change. ... Determine the scope. ... Identify stakeholders and the change management team. ... Clarify the expected benefits. ... Milestones as well as costs must also be clearly outlined. ... Create a change management communication plan.
What should a handoff report include?
Nurses complete their handoff report with evaluations of the patient's response to nursing and medical interventions, the effectiveness of the patient-care plan, and the goals and outcomes for the patient. This category also includes evaluation of the patient's response to care, such as progress toward goals.
Which element is an important component of a nursing shift to shift report?
Written by nurses who are wrapping up their shifts and provided to those nurses beginning the next shift, these details should include a patient's current medical status, along with his or her medical history, individual medication needs, allergies, a record of the patient's pain levels and a pain management plan, as ...