Mrs. Perez’s nurse receives her from the postanesthesia care recovery unit (PACU) to her surgical unit. She realizes that orders are all discontinued when a patient leaves a floor and goes to the surgical suite for surgery. She is looking to admit her patient to her unit and needs a full order set for Mrs. Perez’s care from her surgeon for her postoperative care on the surgical unit. When the patient arrives, the nurse reviews all the new orders the surgeon has written for Mrs. Perez. The nurse will need to introduce herself and have the patient identify herself with two indicators. Once she has done that, she will then do the following to implement the nursing admission to the surgical unit: Interview the patient and/or husband and complete a history. Take vital signs and complete a physical examination. Create a
Mrs. Perez’s nurse receives her from the postanesthesia care recovery unit (PACU) to her surgical unit. She realizes that orders are all discontinued when a patient leaves a floor and goes to the surgical suite for surgery. She is looking to admit her patient to her unit and needs a full order set for Mrs. Perez’s care from her surgeon for her postoperative care on the surgical unit. When the patient arrives, the nurse reviews all the new orders the surgeon has written for Mrs. Perez. The nurse will need to introduce herself and have the patient identify herself with two indicators. Once she has done that, she will then do the following to implement the nursing admission to the surgical unit: Interview the patient and/or husband and complete a history. Take vital signs and complete a physical examination. Create a
Comprehensive Medical Assisting: Administrative and Clinical Competencies (MindTap Course List)
6th Edition
ISBN:9781305964792
Author:Wilburta Q. Lindh, Carol D. Tamparo, Barbara M. Dahl, Julie Morris, Cindy Correa
Publisher:Wilburta Q. Lindh, Carol D. Tamparo, Barbara M. Dahl, Julie Morris, Cindy Correa
Chapter13: Medical Records Management
Section: Chapter Questions
Problem 13.2CS
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Mrs. Perez’s nurse receives her from the postanesthesia care recovery unit (PACU) to her surgical unit. She realizes that orders are all discontinued when a patient leaves a floor and goes to the surgical suite for surgery. She is looking to admit her patient to her unit and needs a full order set for Mrs. Perez’s care from her surgeon for her postoperative care on the surgical unit. When the patient arrives, the nurse reviews all the new orders the surgeon has written for Mrs. Perez. The nurse will need to introduce herself and have the patient identify herself with two indicators. Once she has done that, she will then do the following to implement the nursing admission to the surgical unit:
Interview the patient and/or husband and complete a history.
Take vital signs and complete a physical examination.
Create a care plan for the patient having acute pain postoperatively.
Write an admission note using SOAPIE format (Subjective Data, Objective Data, Assessment, Plan, Implementation, Evaluation).
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