Hi there! Welcome back. Today we're talking about patient research. If you
are new to clinical or have not been practicing for a while this is a
beginner's introduction to gathering relevant information so that you can
safely care for your first patient. So when you're conducting patient research
we're really looking for three key areas of information to gather: the first is
what I will call demographic data. We're looking for the patient's name, their age,
and gender, and where can I find them what room are they in; in addition we're
going to be looking for allergies and their code status - that is a critical
piece of information to have should you walk into that room and your patient not
be responsive. The second category is their medical information. So what's
their reason for admission, what is their past medical history, and their
medications and I like to also look at their PRN medications - they're ones that
they get as needed so I know how I can intervene should again I walk in to a
situation that is not controlled. Lastly these, the last group of information
we're looking for is patients specific care goals, our head-to-toe guidelines. So
I need to know in terms of mobility, diet, elimination. Now you may be looking at
several areas in a patient's binder to gather the information you need. This is
a pretend patient and we'll just look at some of the documents that I will be
using to fill out my patient research form. Mr. Manner here, I've got my
physician orders, he's a new admission, so I can find a great deal of information
on this page. I have his diagnosis, his past medical history and I've got a
whole list of interventions which is going to help me plan my day. If you
don't have access to the admitting orders that may be because your patients
binder has been thinned out which means they've just removed some of the bulk. So
you're gonna have to be more creative as to where you're going to find that
information. Another form, because this patient has diabetes, is we have a blood
glucose record, and this will help give me a sense of
where his sugars have been and how we are managing them. If your facility has a
wound document you can locate that information and it will give you great
insight into the wound itself and the dressing requirements. And then there'll
be documents such as diagnostics, lab results, x-rays, consults, that will also
be part of your gathering information. In the consult section sometimes you'll find past
medical history, in the progress notes of various other professionals you will
find past medical history - use all of your resources within that binder to
locate the general information you need to start caring for your patients safely.
All right so we are at the free download portion! I have created for you
a template that you can use in any work environment. Download this and you can
modify it, it as a Word document to fit your workplace. It is created with a medicine
or surgical floor in mind but as you progress through your practice you will
find that you're modifying this to fit your needs.
So looking at the demographic data I can see Mr Manner is a 74 year old male he is
in room 210 bed 3 he's a full code admitted March 6 and has no isolation
precautions and no allergies. I have an admission diagnosis of urosepsis which
takes me into my medical data. I gathered from the physicians orders a medical
history of osteoarthritis, insulin dependent diabetes mellitus, and atrial
fibrillation in addition to his surgery. I was also able to gather the
medications off of the physician orders which would also be documented in the
patient's medication administration record. The system data is more of a
circle / check list. So for CNS I don't necessarily know if
he's alert to name place and date but if I were to look back into the past
nursing document I may find that information. I also know from looking at
the previous medication administration that he has had abdominal pain it was six
out of ten and he received tylenol at six
in the morning. The effect of which I'm not sure of. I can then just circle the
mobility that fits this patient. It saves time in writing, and then you would fill
out the rest of your systems in the same manner. Looking at cardiovascular he does,
have an IV normal saline running at a hundred milliliters per hour.
I know he has that abdominal dressing and from my wound chart I get some
information about the type of dressing and what the wound looks like should I
need to do that dressing. With the vital signs the history or the trend - it is
important to look at their vital sign record to identify what their normal
ranges are. So for example we'll say Mr. Manner usually sits between 140 and 150
systolic over 70s diastolic. This will help you in assessing whether he is in a
crisis or if he is in his normal range. If you were to do a vital signs on Mr.
Manner and his blood pressure were to be 148 systolic, you would recognize he's in
his normal range and not panic as to him being hypertensive at that moment. In the
respiratory system we can find our parameters if there are orders to keep
SATs over 92, sometimes in our COPD patients they'll be SATs greater than 88
this is an important piece to note, and then what interventions you have
available. A GI system for us Mr. Manner is fluid as tolerated but we have him fluid
restricted at 1.5 liters. and his last bowel movement - I have that highlighted
in red because I want you to check that information and then for the other stuff
that's not relevant you can just draw dashes through. As I said as you continue
to work with this document you will remove the pieces that do not fit on
your floor and you will add extra components that make more sense for you.
Now in the right hand column I have an appointment / result section. I like to
get into the practice of keeping track of the
lab work for example and I like to do things by system as well in this section.
So let's just imagine we're gonna send him for a chest x-ray I just put that up
top because it's an appointment. In the cardiovascular system I would look for
elements of the blood work such as red blood cells ,hemoglobin, white blood cells,
and the breakdown of same. In the respiratory system you may find you have
an arterial blood gas to look at. The GI system is all your electrolytes your
liver profile and in the GU system we're looking at your urinalysis, cultures etc. So
if you get in the practice of putting the lab results in the system in which
they are most relevant to, when you go to give your report to nurses or physicians,
you will have a complete picture of your patient status. Well that's it for me for
today. Thanks for sticking with me. Don't forget to subscribe down below you'll
get the next video when it is released. Have a great day ! :)