I56 Yes Notes sensory impairments I90 Yes The patients right to privacy is

I56 yes notes sensory impairments i90 yes the

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Explains expected sequence of events. (I56) Yes Notes sensory impairments. (I90) Yes The patient's right to privacy is maintained. (O25) Outcomes - Post-op Yes The patient has wound/tissue perfusion consistent with or improved from baseline levels established preoperatively. (O11) Yes Functions as first assistant during surgical incision, excision, and repair of pathology (RNFA). (I129) Yes Evaluates progress of wound healing. (I130) Yes Assesses factors related to risks for ineffective tissue perfusion. (I15) Yes Evaluates postoperative tissue perfusion. (I46) Yes Identifies baseline tissue perfusion. (I60) Yes The patient is at or returning to normothermia at the conclusion of the immediate postoperative period. (O12) Yes Assesses risk for inadvertent hypothermia. (I131) Yes Evaluates response to thermoregulation measures. (I55) Yes Implements thermoregulation measures. (I78) Yes Monitors body temperature. (I86) Yes The patient's respiratory function is consistent with or improved from baseline levels established preoperatively. (O14) Yes Recognizes and reports deviation in arterial blood gas studies. (I110) Yes Uses monitoring equipment to assess respiratory status. (I121) Yes Evaluates postoperative respiratory status. (I45) Yes Monitors changes in respiratory status. (I87) Yes The patient's cardiovascular status is consistent with or improved from baseline levels established preoperatively. (O15) Yes Uses monitoring equipment to assess cardiac status. (I120) Yes Evaluates postoperative cardiac status. (I44) Yes Identifies and reports the presence of implantable cardiac devices. (I58) Yes Identifies baseline cardiac status. (I59) Yes The patient is the recipient of competent and ethical care within legal standards of practice. (O26) Yes Acts as a patient advocate by protecting the patient from incompetent, unethical, or illegal practices. (I1) Yes Provides care respecting worth and dignity regardless of diagnosis, disease process, procedure, or projected outcome. (I100) Yes Provides care without prejudicial behavior. (I102) Yes Shares patient information only with those directly involved in care. (I116) Yes The patient demonstrates and/or reports adequate pain control throughout the perioperative period. (O29) Yes Assesses pain control. (I16) Yes Collaborates in initiating patient-controlled analgesia. (I24) Yes Evaluates response to pain management interventions. (I54) Yes Implements alternative methods of pain control. (I69) Yes Implements pain guidelines. (I71) Yes The patient's neurological status is consistent with or improved from baseline levels established preoperatively. (O30) Yes Assesses baseline neurological status. (I144) Yes Implements protective measures during neurosurgical procedures. (I145) Yes Evaluates postoperative neurological status. (I146) Yes Identifies physiological status. (I66) Yes Maintains patient's dignity and privacy. (I150) Diagnoses Acute confusion (X11) Risk for infection (X28) Risk for injury (X29) Deficient knowledge (X30) Acute pain (X38) Anxiety (X4) Risk for impaired skin integrity (X51) Risk for imbalanced body temperature (X57) Yes Maintains patient confidentiality. (I151) Yes The patient is the recipient of competent and ethical care within legal standards of practice. (O26) Description (Code) Used? Description (Code) Present?
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IP Encounter Report
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