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Scenario: Question 45 refers to this scenario. You are receiving a verbal shift report for one of your assigned patients. You are using your own sell-prepared form on which to write the necessary data that you will need to provide continuity of care for this patient The patient is Julie James, and she is in Room 417. Her diagnosis is COPD, and she has no known drug allergies. She is 69 years old. Her physician is Dr. Taylor. She was admitted on 08/24/22. She needs a CXR and a UA done today. Her medications on your shift from 7:00 a.m. to 3:30 p.m. are due at 9:00 a.m., 12:00p.m., 2:00p.m., and 3:00 p.m. She has an IV with a 22-gauge intracath in her left forearm. It is infusing at the prescribed rate of 30 milliliters per hour with an W pump. There is a physician’s order to convert the IV to a saline lock this morning. Then a soapsuds enema is ordered. She can be up in the room as she desires and has a BSC in the room. Her vital signs are ordered every 2 hours. They will be due again beginning at 8:00 a.m. She is to be up in the chair for her meals. She has continuous oxygen ordered at 2 liters per minute, delivered by a nasal cannula. Spo, will also be assessed with her vitals every 2 hours. She is to have a low- sodium diet . She is able to shower with standby assistance and should have mouth care after each meal. The physician has ordered I/O to be monitored. She has not had a BM in 2 days. 45. Using the template in Figure 5.2, create your own Pocket Brains with the appropriate blanks for the required data that you will need to document for this patient on your 8-hour shift. You may alter the format to your own design: just be certain to include all necessary components and make it as functional as you can. Figure 5.2 Podiat Brains
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