ANSWER
An thorough summary of Wallace Peterson’s medical information is included in this patient chart, together with his personal information, hospital records, and other educational and healthcare standards resources. Take into account the following advice to approach the simulation accurately and professionally:
Important Things to Consider: Synopsis of the Situation:
Recognize the patient’s condition and any unique problems that could impact treatment. Wallace Peterson’s salt restriction, for example, raises the possibility of renal or cardiovascular issues.
Provider Diagrams:
Understanding the tests, treatments, and justification for care depends on the provider orders as well as the history and physical.
For information on the patient’s state and reaction to interventions, pay close attention to the Progress Notes.
Charting of Patients:
To determine baseline medical conditions, review the admission history and system assessments.
Check Vital Signs for trends and anomalies over time.
Laboratory Examinations:
Use the Order Results tab to help you understand the tests that were conducted, their necessity, and how they relate to the patient’s condition while you complete the lab test portion of your project.
Orders for medications and pharmacies:
A patient’s medication administration record may shed light on how their sodium-restricted diet and other circumstances influence their drug selections.
Resources Available:
To support your research and guarantee evidence-based care, use the links provided to reputable sources like the CDC, QSEN, and MedlinePlus.
Finishing the Task:
Determine and describe pertinent tests for the lab test research based on Wallace Peterson’s age, diet, and medical background.
Examples include a lipid panel for cardiovascular risk, an electrolyte panel for sodium levels, and kidney function tests (creatinine, BUN).
Explain why each test was requested, any potential aberrant findings, and how they relate to his overall health and sodium-restricted diet.
To learn about the best practices for patient safety and high-quality care, use resources such as AHRQ and QSEN.
Do you need assistance creating portions of the lab test assignment or deciphering particular chart sections?
QUESTION
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PATIENT: Peterson, Wallace DOB: 06/06/1954 AGE: 69 GENDER: MALE
MRN: 7214732 HOSPITAL FLOOR: Med-Surg ROOM: 327 HCP: Lois Myer, MD
CODE STATUS: FULL CODE ISOLATION: Standard ALERTS: None
DRUG ALLERGIES: NKDA ENVIRONMENTAL ALLERGIES: NKA FOOD ALLERGIES: NKA
DIET: Sodium-Controlled HEIGHT: 5’ 7” WEIGHT: 131 lbs. BMI: 20.5
PATIENT CHART TABS
➢ SCENARIO SUMMARY
➢ PROVIDER CHARTS: PROVIDER ORDERS
➢ PROVIDER CHARTS: HISTORY & PHYSICAL
➢ PROVIDER CHARTS: PROGRESS NOTES
➢ PROVIDER CHARTS: CONSULTATION REPORTS
➢ PATIENT CHARTING: ADMISSION HISTORY
➢ PATIENT CHARTING: SYSTEM ASSESSMENTS
➢ PATIENT CHARTING: IV’s
➢ VITAL SIGNS: VITAL SIGNS
➢ VITAL SIGNS: INTAKE/OUTPUT
➢ VITAL SIGNS: BLOOD GLUCOSE
➢ VITAL SIGNS: HEIGHT & WEIGHT
➢ ORDER ENTRY – PHARMACY
➢ ORDER RESULTS
➢ PATIENT CARD
➢ MEDICATION ADMINISTRATION RECORD
➢ OTHER DEPARTMENTS: AMBULATORY & EMERGENCY
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SCENARIO SUMMARY
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PROVIDER CHARTS: PROVIDER ORDERS
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PROVIDER CHARTS: HISTORY & PHYSICAL
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PROVIDER CHARTS: PROGRESS NOTES
PROVIDER CHARTS: CONSULTATION REPORTS
PATIENT CHARTING: ADMISSION HISTORY
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PATIENT CHARTING: ADMISSION HISTORY CONTINUED…
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PATIENT CHARTING: ADMISSION HISTORY CONTINUED…
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PATIENT CHARTING: ADMISSION HISTORY CONTINUED…
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PATIENT CHARTING: ADMISSION HISTORY CONTINUED…
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PATIENT CHARTING: ADMISSION HISTORY CONTINUED…
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PATIENT CHARTING: ADMISSION HISTORY CONTINUED…
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PATIENT CHARTING: ADMISSION HISTORY CONTINUED…
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PATIENT CHARTING: ADMISSION HISTORY CONTINUED…
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PATIENT CHARTING: ADMISSION HISTORY CONTINUED…
PATIENT CHARTING: SYSTEM ASSESSMENTS
SYSTEM ASSESSMENTS INTERVENTIONS
BASIC NURSING CARE
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PATIENT CHARTING: SYSTEM ASSESSMENTS PATIENT CHARTING SUMMARIES
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PATIENT CHARTING: SYSTEM ASSESSMENTS PATIENT CHARTING SUMMARIES CONTINUED..
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PATIENT CHARTING: IV’s
VITAL SIGNS: VITAL SIGNS
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VITAL SIGNS: INTAKE/OUTPUT
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VITAL SIGNS: HEIGHT/WEIGHT
VITAL SIGNS: BLOOD GLUCOSE
ORDER ENTRY – PHARMACY
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ORDER RESULTS
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PATIENT CARD
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MEDICATION ADMINISTRATION RECORD
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OTHER DEPARTMENTS: AMBULATORY & EMERGENCY OB TRIAGE NOTES
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STUEDENT RESOURCES:
Centers for Disease Control and Prevention (CDC)
The CDC is the central authority for Health Care information. From this site, the user may explore national standards, find specialized patient teaching, and follow emergency trends of health and disease in the United States.
http://www.cdc.gov
CDC: Vaccines & Immunizations
This dedicated CDC site focuses on immunization standards and infection control trends. Stay up to date with the current standards by monitoring this site.
http://www.cdc.gov/vaccines/
Quality and Safety Education for Nurses (QSEN)
QSEN is a comprehensive resource for quality and safety education for nurses. From this site, the reader can find detailed information about the knowledge, skills and attitudes nurses need related to patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.
http://www.qsen.org/
The Joint Commission
The Joint Commission is the gatekeeper for hospital accreditation. This organization monitors hospital quality, establishes monitoring and accreditation standards, and serves as the institutional watch dog on behalf of the public. This important website lists patient care standards and monitoring trends.
http://www.jointcommission.org/
Agency for Healthcare Research and Quality (AHRQ)
This extremely rich and valuable interdisciplinary site is sponsored by the U.S. Department of Health and Human Services. The site serves as the National Guideline Clearinghouse for a wide variety of health care problems and diseases.
http://www.guideline.gov/
Institute of Health Care Improvement
The institute of Health Care Improvement is a nonprofit organization dedicated to providing safe and effective healthcare to patients. The Programs and Topics sections of this website offer valuable information about best practices and national practice standards.
http://www.ihi.org/ihi/programs
Institute for Safe Medication Practices (ISMP)
ISMP is a nonprofit organization dedicated to educating the healthcare community and consumers about safe medication practice. This site is an excellent resource for information related to medication standards, education, and monitoring.
http://www.ismp.org/
Institute of Medicine (IOM)
The IOM is part of the National Academies. The purpose of this organization is to advise the nation as how to improve health. The IOM may address clinical issues such as the safety of medication administration in addition to advising the nation as to the health and direction of a specific discipline such as nursing.
http://www.iom.edu/
MedlinePlus MedlinePlus, sponsored by the National Institute of Health, provides information regarding various health topics, drugs and supplements, and related information.
http://www.nlm.nih.gov/medlineplus/
Medline and PubMed
Medline and PubMed is The National Library of Medicine’s database covering the fields of nursing, medicine, and a variety of other clinical and preclinical services.
http://www.nlm.nih.gov/databases/da tabases_medline.html
NANDA International
NANDA International is an organization dedicated to the support of an international community of nurses equipped with a common language of nursing diagnoses to further patient care. Access a global network of nurses from this site and take part in the evolution of nursing diagnoses and care planning.
Canadian Nurses Association (CNA)
Canadian Nurses Association (CNA) is the national voice of registered nurses in Canada. CNA works to improve health outcomes and strengthen the publicly funded, not-for-profit health system. The site contains valuable information about becoming a registered nurse, professional development, current issues, and the benefits of joining CNA.
http://www.cna-aiic.ca/en
American Nurses Association (ANA)
The American Nurses Association (ANA) is the premier organization representing the interests of the nation’s 4 million registered nurses. ANA is at the forefront of improving the quality of health care for all. Founded in 1896, and with members in all 50 states and U.S. territories, ANA is the strongest voice for the profession. ANA exists to advance the nursing profession by fostering high standards of nursing practice, promoting a safe and ethical work environment, bolstering the health and wellness of nurses, and advocating on health care issues that affect nurses and the public.
https://www.nursingworld.org