Nursing Physician Notes

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Author:
Anonymous
ID:
8800
Filename:
Nursing Physician Notes
Updated:
2010-03-02 03:53:49
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basic patient care nursing physician notes janice
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Basic Patient Care Nursing Physician Notes
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  1. Why is nurse physician communication important?
    • Patient Safety
    • Job Satiation
    • Job Stress
  2. Central elements of communication
    • Mutual Trust
    • Respect
    • Shared Decision making responsibilities
  3. How can nurses improve nurse/physician relationships?
    • Nurses must be able to approach physicians as equal professional colleagues
    • Collegial
    • respectful
    • problem solving manner: nurse must assume responsibility for the quality of relationships with physicians
    • Team strategy
  4. Empowering nurses are:
    • secure in their knowledge and clincal expertise
    • up to date with advances in their specialty
    • Continuing education
    • specialty certification
    • professional organizations
    • go to conferences
    • informal collaborative work groups
    • Serve on interdisciplinary committees: Nurses who take pride in their expertise
  5. Stereotypes are rapidly changing from
    • hierarchiacial to autonomous
    • team approach
  6. How to approach a physician
    • Topic: appropriate for physician, appropriate question/discussion
    • timing
    • SBAR
  7. SBAR is:
    • Situation
    • Background
    • Assessment
    • Recommendation
  8. Situation (SBAR)
    • Describe current situation using concise factual descriptions.
    • Change in conditions, vital signs
    • Abnormal lab values
    • patient falls
    • medication reaction
    • blood transfusion reaction
  9. Background (SBAR)
    • Provide supporting background information leading to the current event
    • Admission diagnosis
    • Recent vitals
    • Recent lab values
    • recent results
  10. Assessment (SBAR)
    • Sate your interpretation of the situation
    • Use critical thinking to analyze the situation
    • use correct medical terminology
  11. Recommendation (SBAR)
    • Give your recommendation for follow up or treatment
    • Medications
    • Treatments
    • Test education
  12. Where is SBAR used?
    • Shift report
    • Calling MDs
    • Documentation
    • Transport reports
  13. Scenario

    •Mrs..
    Anne Smith
    •82 years old
    •Admitted from home
    •Diagnosis pneumonia
    •Over the last hours she has become SOB with a respiratory rate of 32. Her SpO2 (on 2 L
    of O2) has dropped from 96% to 88%
    • S = Situation: Dr.Green, This is Mary Jones from Five West. I am calling you about Anne Smith. Are you familiar with the patient? She is SOB with a resp. rate of 32 and an O2 sat. of 86 on 2L. I have placed her on a non-rebreather mask and her sats are now 94%.
    • B=Background: She is 82 y.o., Full code, Admitted to the hospital yesterday with pneumonia, She has received 2 does of Levaquin since admit, Her VS10 minutes ago were 36.5, 75, 22, 138/60 and 95% on 2L.
    • A=Assessment: I believe she is developing respiratory failure
    • R=Recommendation: I would like to an order for a chest x-ray, ABGs and an Albuterol nebulizer treatment.

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