Professional Documents
Culture Documents
Anecdotal Notes Week 2
Anecdotal Notes Week 2
« Contact Isolation
« Observation- Maintained the practice for contact isolation to prevent the disease's spread.
« Recommendation: Follow the same practice
Maintain the dignity of the patient- incontinent of urine and she decided to put him on toileting
protocol every 2hrs.
advocacy-She was aware that the patient was NPO for the EGD. She was proactive -In the beginning
of the shift she communicated with the unit clerk for the confirmation of the procedure if it will push
through.
Anxious about the procedure and wanting something to calm him down during the procedure-she
did communicate with the staff, she also explained the procedure to reduce anxiety.
Scheduled med-Nadolol -she found it in the patient bed- she was not sure that it was the dose she
gave or the previous one- she reported and documented, but did not give the dose again.
Recommendation: Next time she should watch the patient to swallow the meds.
Took patient for a walk, 1 lap- she monitored patient oxygen status and documented
Ø Braden scale and risk for fall
Ø Observation: She assessed and documented the findings.
Ø Recommendation: Continue the right process
-Attempted IV initiation
Education
Determinant of health
Care Plan
Goals: 3.4
Megan R:
Scenario: enteral tube feed: on boarding- did not read the policy and the progress note before
meeting the client- More prompting required- demonstration to her.
Tinzaparin- She did not read the monograph- she was not aware- she was aware about the platelet
count.
BEFORE ADMINISTERING ANY S/C, IM, IV- parenteral-meds always reference adult parenteral
monograph
Interacted with the patient son and asked him- their prospective
Education
Determinant of health
Care Plan
Goals: 3.4
Ø Braden scale and risk for fall- she did not documented- performed
Ø Observation: She assessed and documented the findings.
Ø Recommendation: Continue the right process
§ Observations: Assessment, vital signs and glasgow coma scale were all documented all in real-
time;
Am care -she provided good aaam care- total care- buddied with brooklyn- 3.2-collaboration- she
got an exposure to the role of occupational therapist and how she will be mobilizing the patient.
Brooklyn;
Education
Determinant of health
Care Plan
Goals: 3.4
Ø Braden scale and risk for fall- she did not documented- performed
Ø Observation: She assessed and documented the findings.
Ø Recommendation: Continue the right process
Am care -she provided good am care- total care- buddied with Megan R- 3.2-collaboration-
All three students: brooklyn, Megan?, chelsea- helped the confused patient in a hallway -
observation was done by the primary nurse.