2 3 4 Path to Discharge Path to Death or Injury None DYB F 32 Full Chronic Low

2 3 4 path to discharge path to death or injury none

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2. 3. 4. Path to Discharge: Path to Death or Injury: None DYB F 32 Full Chronic Low Back Pain None 11/12/2020 Dr. Clinic Self Room Self Low Hepatic Panel Lab Pain Center Patient 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 medication Patient will be educated about the proper dosing of medication Patient 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 injury Clinical Worksheet
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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? 1. 2. 3. 4. Management of Care: What needs to be done for this Patient Today? 1. 2. 3. 4. 5. 6. Priorities for Managing the Patient’s Care Today 1. 2. 3. 4. What aspects of the patient care can be Delegated and who can do it? Medication Error Chronic back pain Neuro Assessment Head to Toe Assessment Neuro Assessment Vital Assessment Chronic physical disability Chronic psychological disability Risk of Injury Allow 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 ordered Discuss 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 patient Manage patient pain relief Perform Head to Toe Assessment on patient Educated patient about herbal supplements Educated patient about OTC medications Educate patient about medication errors. Maintaining chronic back pain Educate about medications Educate patient about possible constipation Educate about pain management and hydration Doctor – Patient care Nurse- Assessment, Patient Care Pain Center – Pain Mangement/Education
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