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2. 3. 4. Path to Discharge:Path to Death or Injury:NoneDYBF32FullChronic Low Back PainNone11/12/2020Dr. ClinicSelf RoomSelfLowHepatic Panel Lab Pain CenterPatient came to the clinic today with complaints of a persistent cough and fatigue that have lasted for 2 weeks. It started as a common cold, but she was concerned that it was something more serious since the cough and fatigue have not resolved yet.Ms. Young Bear is a 32-year-old Native American female. She is not one of our regular patients, but her usual provider is on vacation so she was referred to our clinic.She has a history of low back pain acquired at her job as a construction worker, and she is also being medicated for depression.Patient will have a neuro assessment Patient will be educated about excessive medicationPatient will be educated about the proper dosing of medicationPatient will be reccommended to a pain center.Patient will be referred to a pain center to help her tolerate her back pain. Patient will go home with new orders on intake of medication.Risk of overdose, Risk of infection, risk of severe injuryClinical Worksheet
Alerts:What are you on alert for with this patient? (Signs & Symptoms)1.2.3.What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?)1.2.3.List Complications may occur related to dx, procedure, comorbidities:1.2.3.What nursing or medical interventions may prevent the above Alert or complications?188.8.131.52.Management of Care: What needs to be done for this Patient Today? 184.108.40.206.5.6.Priorities for Managing the Patient’s Care Today220.127.116.11.What aspects of the patient care can be Delegated and who can do it?Medication ErrorChronic back painNeuro AssessmentHead to Toe AssessmentNeuro Assessment Vital AssessmentChronic physical disabilityChronic psychological disabilityRisk of InjuryAllow patient to maintain a diary of pain ratings, timing, precipitating events, medications, treatments, and what works best to relieve pain.Educate patient of pain management approach that has been orderedDiscuss patient’s fears of undertreated pain, addiction, and overdose.Maintain the patient’s use of nonpharmacological methods to control pain, such as distraction, imagery, relaxation, massage, and heat and cold application.Assess Neuro Exam on patientManage patient pain reliefPerform Head to Toe Assessment on patientEducated patient about herbal supplementsEducated patient about OTC medicationsEducate patient about medication errors.Maintaining chronic back painEducate about medicationsEducate patient about possible constipationEducate about pain management and hydrationDoctor – Patient careNurse- Assessment, Patient CarePain Center – Pain Mangement/Education