Dentists
Registered Nurses
Physician Assistants (PA)
Certified Nurse Midwives (CNM)
Patient's condition and the cost of admission per day
Facility policy and the patient's distance from home
Patient's condition and the facility policy
Facility policy and patient's request
Evaluate patient
Obtain patient's history
Transcribe doctor's orders
Obtain patient's vital signs, height, and weight
Pass
Discharge
Subsisting elsewhere
Absent without leave (AWOL)
56
66
76
10
On pass
Subsisting out
On convalescent leave
Discharged and an outpatient
Patient was likely off the unit having tests completed
Patient is doing well and no problems were noted
Doctor probably changed the orders verbally
Vital signs were not completed
No documentation is required at shift change
Document all totals in the Remarks section
Document in the Grand Total block
Circle the last accumulated total
Planning
Assessing
Evaluating
Implementing
An observable change in patient behavior
A measurable change in the patient's condition
A realistic and measurable statement of the end results of care planning
A realistic and measurable statement of the expected change in patient behavior
Sedation
Back massage
Oxygen therapy
Preoperative teaching
Credentials of the surgeon
Availability of a base chaplain
Professionalism and caring attitude of the staff
Number of nurses and technicians on staff
Reduces chance of infection
Prevents contamination of the operating room (OR)
Allows for proper suturing of the incision
Reduces pain when the surgical dressing is removed
15
30
45
60
Isolation is necessary
No precautions re necessary
A lead apron is placed over the patient
Lead aprons are placed on other recovery patients
Low
High
Fowler's
Trendelenburg
Standing hamstring stretches
Turn, cough and deep breath (TC&DB)
Diaphragmatic breathing
Circles with the big toe
Standard Form 518
Standard Form 3066
AF Form 2019
AF Form 3066
100 cc units
250 cc units
450 cc units
500 cc units
20
30
60
90
Continue to monitor; this is a normal side effect
Place the patient on his or her left side
Administer 100 percent oxygen
Stop the transfusion
Application of transcutaneous electrical nerve stimulation (TENS) devices
Injection of long duration local anesthetic into the incisional area
Administration of oral analgesics
Administration of narcotics
Modified lateral
Trendelenburg
Semisitting
Supine
Infectious
Congenital
Pathologic
Temporary
Hairline
Pathologic
Congenital
Traumatic
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