.
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 the 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 are 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.
Trendelenberg.
Semisitting.
Supine.
Infectious
Congenital
Pathologic
Temporary
Hairline
Pathologic
Congenital
Traumatic
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