Patient Feedback Log & Score | Study notes Chemical Thermodynamics | Docsity (2024)

Download Patient Feedback Log & Score and more Study notes Chemical Thermodynamics in PDF only on Docsity! Sara Lin Age: 18 years Diagnosis:Appendectomy 9/18/202 0 Feedback Log & Score — Sara Lin Apr 18, 2020 11:42 PM Date of Completion Apr 18, 2020 11:42 PM Score 0 0 0 100% Feedback Log 0:00You arrived at the patient's side. 0:00You reviewed the patient information. 0:00You reviewed the patient log. 0:00You reviewed the diagnostics. 0:00You reviewed the clinical observations. 9/18/202 0 Feedback Log & Score — Sara Lin Apr 18, 2020 11:42 PM 0:00 You reviewed the MAR. 0:00 You reviewed the orders. 0:00 You reviewed the intake and output. 0:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 138/82 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 97%. Temp: 99 F (37.2 C) 0:12 You introduced yourself. This was reasonable. 0:19 You washed your hands. To maintain patient safety, it is important to wash your hands as soon as you enter the room. 1:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 137/82 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37.1 C) 1:34 You identified the patient. To maintain patient safety, it is important that you quickly identify the patient. 1:44 You asked if the patient was <Allergy>allergic<> to anything. (In pain) She replied: 'No, I am not allergic to anything.' 1:56 You asked the patient if she had any pain. (In pain) She replied: 'Yes! Ahh...&apo s; 2:01 You asked the patient if anything made the pain better. (In pain) She replied: 'If I lay perfectly still, it is better.' 2:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 137/83 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37.1 C) 2:12 You asked the patient if anything made the pain worse. (In pain) She replied: 'Yes, it gets worse by deep breathing and coughing.' 2:21 You asked the patient if she could describe her pain. (In pain) She replied: 'I feel a sharp pain on the side, and my belly hurts and kind of throbs.' 2:32 You asked: How would you rate your pain? (In pain) She replied: 'It's pretty bad; I'd give it a 6. ' 2:43 You asked the patient: Where does it hurt? (In pain) She replied: 'Just my belly, nowhere else really.' 2:56 You asked the patient if she needed anything for the pain. (In pain) She replied: 'Yes. Please!' 9/18/202 0 Feedback Log & Score — Sara Lin Apr 18, 2020 11:42 PM6:01 You asked the patient: Have you had increased swelling of the legs the last week? (In pain) She replied: 'No, they have been about the same size.' 6:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 138/82 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 9/18/202 0 Feedback Log & Score — Sara Lin Apr 18, 2020 11:42 PM6:13 You asked the patient: Have you had any signs of urinary tract infection like fever, urge, or pain? (In pain) She replied: 'No, I have not felt any of that.' 6:27 You asked the patient: Have the urine volume and color been normal? (In pain) She replied: 'Yes, it has been as usual.' 6:37 You asked if the patient was <Allergy>allergic<> to anything. (In pain) She replied: 'No, I am not allergic to anything.' 6:45 You asked the patient what medication she was taking, if any. (In pain) She replied: 'No, I don't take any medication.' 6:54 You asked the patient if she had any medical problems. (In pain) She replied: 'No, I don't have any medical problems.' 7:01 You asked the patient if she was a smoker. (In pain) She replied: 'No, I don't smoke.' 7:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 137/82 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 7:11 You asked the patient if she was awake. (In pain) She replied: 'Yes, I am.' 7:16 You asked the patient what year it is. (In pain) She replied: 'It is 2020.' 7:22 You asked the patient if she knew where she was. (In pain) She replied: 'I'm at the hospital.' 7:29 You asked the patient what date it was. (In pain) She replied: 'The (In pain) 18th' 7:41 You put on gloves. 7:55 You examined the patient's head. There is no obvious airway obstruction. There is normal elasticity of the skin. Her skin is cool, and she is very sweaty. 8:10 You examined the patient's chest. She is breathing at 21 breaths per minute. The chest is moving equally. 8:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 136/81 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 8:21 You examined the patient's abdomen and pelvis. There is a dressing covering the skin lesion on the abdomen. There is nothing else to find on examination of the abdomen and pelvis. 8:36 You examined the patient's arms. There is nothing to find on 9/18/202 0 Feedback Log & Score — Sara Lin Apr 18, 2020 11:42 PMexamination of the arms. 8:45 You examined the patient's legs. There is nothing to find on examination of the legs. It's appropriate to perform a physical head-to-toe examination. 9:05 You assessed the mucous membranes. This was reasonable. This study source was downloa9de:d1b0y 1000P00a8t2ie3n82t2s0t3a2tufrsom- ECoCuGrse:HSeirnou.csomrhoynt0h4m-1.8H- 2e02a1rt01ra:5t0e::499G5.MPTu-l0s5e:0:0Present. Blood pressure: 139/83 9/18/202 0 Feedback Log & Score — Sara Lin Apr 18, 2020 11:42 PM14:39 You checked the eye movements. Extraocular movements within normal limits. 14:59 You checked the patient's pupils, and they were 6 mm and reactive. 15:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 136/82 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 15:21 You assessed the patient's neurological status. 16:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 137/82 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 16:55 You assessed the patient's dressing. This is correct. Assessing any dressings the patient has is always important. 17:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 138/82 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 18:00 You encouraged coughing. 18:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 138/82 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 18:27 You educated the patient about activities, safety, and fall risk. 18:51 You educated the patient about coughing. 19:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 136/81 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 19:17 You educated the patient about diagnostics. 19:33 You educated the patient about diet. 19:52 You educated the patient about improving venous return. This was reasonable. 20:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 137/82 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 20:27 You educated the patient about medication. 21:01 You educated the patient about oxygen therapy. 21:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 138/83 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 21:32 You educated the patient about positioning. 9/18/202 0 Feedback Log & Score — Sara Lin Apr 18, 2020 11:42 PM 21:50 You educated the patient about use of incentive spirometer. This was indicated by order. 22:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 137/82 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 22:19 You educated the patient about wound care. This was reasonable. 9/18/202 0 Feedback Log & Score — Sara Lin Apr 18, 2020 11:42 PM23:01 You encouraged coughing. 23:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 139/83 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 23:21 You encouraged coughing. 23:53 The patient used an incentive spirometer. This was indicated by order. 24:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 138/82 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 25:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 137/82 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 26:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 140/83 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 27:01 You compared the medication label with MAR. This was reasonable. 27:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 138/83 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 27:36 A 5-mg dose of oxycodone was given orally. It is important to use the basic rights of medication administration to ensure proper drug therapy. This was indicated by order. 28:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 135/81 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 28:26 You compared the medication label with MAR. This was reasonable. 29:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 138/82 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 29:23 A 325-mg dose of acetaminophen was given orally. This was reasonable. 30:00 You compared the medication label with MAR. This was reasonable. 30:10 Patient status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 138/82 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 98%. Temp: 99 F (37 C) 30:12 A 500-mg dose of levofloxacin was given orally. This was indicated by order. 30:31 You phoned the provider in order to discuss