I feel this week in practice, that I made significant improvement with my time management and organisation of my priorities. I was able to get my documenting done in a timelier manner. Using the IDRAW spreadsheet with the time blocks, I wrote in at the beginning of my shift what the tasks were that I needed to be complete and at what time. I laid out my initial priorities as follows.
• Find clients primary care nurse (ask about any changes or what to look for)
• Safety assessment and priority assessment of my client
• Address immediate concerns (my client was complaining of nausea)
• Confer with primary care nurse about antiemetic medication
• Document
• Administer antiemetic
• Document
• Review client care plan
• Heat-to to assessment (client …show more content…
I found by setting a fluid schedule, it helped keep me on task and enabling myself to recognize and feel how being more efficient allows me to get more task done, as well as decrease my stress (which takes away from focus of my client, tasks and healing …show more content…
She was not presenting and signs (increased heartrate, grimacing, etc.) of severe pain. I do understand that pain is subjective and if a client has pain, I cannon interpret how much pain they are in. What I found to be the challenge in this scenario is that because my client was not presenting as if someone was in severe pain and I was administering a strong opioid, then maybe the analgesic was more than what maybe my client needed? I learned from my clients chart that she regular drinks up to a bottle of wine per day, as well as from my client that the two weeks she has been in the hospital is the longest she have ever gone without drinking alcohol. I was confident my client was in pain, however I was wondering if perhaps the narcotic was replacing some of the feelings that alcohol gave. Maybe I have not write to think about this or and certainly not to make any assumptions. I did find it useful with a reminder from my instructor to document objective data that I observe. The example in this scenario was: to document the subjective data from my client (8/10 pain) and my objective data (pt. appears comfortable with no grimacing). This enabled me to see that when the HCP reads the notes, he/she can gather both subject and objective data to interpret my client’s health experience which influence the care (i.e.
• Find clients primary care nurse (ask about any changes or what to look for)
• Safety assessment and priority assessment of my client
• Address immediate concerns (my client was complaining of nausea)
• Confer with primary care nurse about antiemetic medication
• Document
• Administer antiemetic
• Document
• Review client care plan
• Heat-to to assessment (client …show more content…
I found by setting a fluid schedule, it helped keep me on task and enabling myself to recognize and feel how being more efficient allows me to get more task done, as well as decrease my stress (which takes away from focus of my client, tasks and healing …show more content…
She was not presenting and signs (increased heartrate, grimacing, etc.) of severe pain. I do understand that pain is subjective and if a client has pain, I cannon interpret how much pain they are in. What I found to be the challenge in this scenario is that because my client was not presenting as if someone was in severe pain and I was administering a strong opioid, then maybe the analgesic was more than what maybe my client needed? I learned from my clients chart that she regular drinks up to a bottle of wine per day, as well as from my client that the two weeks she has been in the hospital is the longest she have ever gone without drinking alcohol. I was confident my client was in pain, however I was wondering if perhaps the narcotic was replacing some of the feelings that alcohol gave. Maybe I have not write to think about this or and certainly not to make any assumptions. I did find it useful with a reminder from my instructor to document objective data that I observe. The example in this scenario was: to document the subjective data from my client (8/10 pain) and my objective data (pt. appears comfortable with no grimacing). This enabled me to see that when the HCP reads the notes, he/she can gather both subject and objective data to interpret my client’s health experience which influence the care (i.e.