In your shift plan did you consider:
• As this patient has had a ? TIA it is important that the patient is assessed by speech pathology prior to any oral medications being given. In this case, a tablet with a small sip of water is still dangerous as it may result in aspiration of the tablet and water into the patient’s lungs. All medications that are oral should be administered after the sip test only
• the patient is charted for nebulisers – did you consider that this patient needs to have nebulisers given with air not oxygen at this patient is a CO2 retainer?
• has repeat CTB in 2 days been ordered? Confirm this has occurred
• frequency of vital signs – as this patient has recently had a neurological change this should be assessed 15minutely for an hour, then hourly for 12-24hours. This should be in combination with neurological assessments
• Physiotherapy referral and review prior to mobilisation in context of cognitive change
• Speech pathology referral in context of possible dysphagia from cerebral change. Ensure patient is NBM until this happens, ensure no diet is ordered in eMR and NBM sign visible/alert in eMR. Ensure patient is aware
• Respiratory assessment to consider possible aspiration when eating dinner last night (time of cognitive change). Patient should have at least daily respiratory assessments until aspiration risk is eliminated. Hourly deep breathing and coughing (patient can do this on their own, but RN needs to ensure it is being done)
• Referral to endocrinology team/diabetic review
– hbA1c blood test
• Wash, shave, teeth brush, teds
• DVT risk – anticoagulation, early mobilisation with physiotherapy and hourly foot and ankle exercises. At least once per shift assessment of deep veins to ensure no DVT developing
• VIP score for P.IVC
• Falls prevention strategies. This patient is moderate risk. What could you do to reduce risk of falls specifically for this patient?
• Stroke guidelines recommend the following blood tests be conducted: full blood count, electrocardiogram, electrolytes, renal function, fasting lipids, erythrocyte sedimentation rate and/or C-reactive protein and glucose. Which of these are done and which need to be ordered?
• Have you done the ECG requested?
• Pantoprazole should be reconsidered in context of renal history – flag this with the medical team
• NSAIDS are also not recommended for patients with renal impairment, however aspirin is recommended for patients with cardiac history (PVD and IHD). Aspirin is also recommended for stroke. Which would take priority for this patient? Should this be reviewed? Apsirin should be continued – we need to monitor renal function then so urine outputs should be measured and EUCs should be ordered for follow up during his admission
• Did you update the FBC?
• Patient’s blood pressure is high. This is not a CR or a RR but still needs to be addressed. If he cannot have his oral antihypertensives, we need to discuss this with the medical team and perhaps get a transdermal patch or sublingual option until his oral medications can resume
• There is a high likelihood, based on this patient’s past medical history, that there are some lifestyle risks and modifiable risk factors which can be addressed to reduce his risk of future stroke. These include exercise and diet modification. Dietician and diabetic educators should be involved. Motivational counselling and psychology services should also be included, and the patient needs to be referred on to a chronic health care management team for these.
• Due to new medications being introduced, the pharmacist should be contacted to provide review of all medications and education to the patient about his new medications
• This patient cannot drive until cleared by a medical professional, and needs to complete the national assessing fitness to drive guidelines. The patient must be informed of this
• Does the patient need glycaemic control medications? Until the patient is eating again this might not be necessary, but as his BSL is elevated we should keep an eye on this and inform the medical team
• This patient should not be started on oxygen as their saturations are within the targeted range for COPD. Did you start this patient on oxygen?
• Refer to stoke and TIA guidelines here: https://www.clinicalguidelines.gov.au/portal/2585/clinical-guidelines-stroke-management- 2017
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speech pathology prior to any oral medications