Description
Shadow Health: Perioperative Care Hourly Rounds Sonia Best
Assignment Description: This assignment provides the opportunity to conduct a perioperative care visit with a patient in a medical surgical setting. You will interview and examine the patient, document your findings, and complete nursing care activities.
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Estimated Time to Complete: 75 minutes
Solution: Shadow Health: Perioperative Care Hourly Rounds Sonia Best
Finding:
Reports checking blood glucose
(Available)
Pro Tip: Nurses are essential in the management of a patient’s diabetes. Asking questions about the patient’s current diabetes medication regimen and management will help you coordinate care and promote the patient’s health and well-being.Example Question:
Do you check your blood glucose?
Finding:
Reports “eating healthy”
Solution:
Category
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.
Patient Check In
Finding:
Reports foot wound
(Found)
Pro Tip: By asking a patient an open question about their reason for coming into the hospital, you can establish their current medical and comfort needs and assist in coordinating their care.Example Question:
What brings you in to the hospital?
Finding:
Reports below-the-knee amputation scheduled
(Found)
Pro Tip: By asking a patient an open question about their reason for coming into the hospital, you can establish their current medical and comfort needs and assist in coordinating their care.Example Question:
What brings you in to the hospital?
Finding:
Asked about patient status
Finding:
Reports doing fine
(Found)
Pro Tip: Asking a patient about their comfort level and current needs ensures a patient’s right to have their basic physical care and comfort needs met.Example Question:
How are you feeling?
Finding:
Asked about patient comfort
Finding:
Reports feeling comfortable
(Found)
Pro Tip: Asking a patient about their comfort level and current needs ensures a patient’s right to have their basic physical care and comfort needs met.Example Question:
Do you feel comfortable?
Finding:
Asked about current needs
Finding:
Reports desire for water
(Found)
Pro Tip: Asking a patient about their comfort level and current needs ensures a patient’s right to have their basic physical care and comfort needs met.Example Question:
Is there anything I can do for you?
Personal Health
Finding:
Asked about elimination
Finding:
Reports needing to use restroom soon
(Found)
Pro Tip: Asking a patient about their comfort level and current needs ensures a patient’s right to have their basic physical care and comfort needs met.Example Question:
Do you need to use the restroom?
Finding:
Asked about pain level
Finding:
Reports 3 out of 10 pain
(Found)
Pro Tip: Asking a patient about their comfort level and current needs ensures a patient’s right to have their basic physical care and comfort needs met.Example Question:
Can you rate your pain level out of 10?
Finding:
Asked about emotional status
Finding:
Reports feeling anxious about surgery
(Found)
Pro Tip: Patients undergoing surgery to amputate a limb are faced with a permanent loss. Asking them open questions about their feelings on the surgery and what coping mechanisms they use will help you coordinate your care.Example Question:
How are you feeling about the surgery?
Finding:
Reports sadness about losing limb
(Available)
Pro Tip: Patients undergoing surgery to amputate a limb are faced with a permanent loss. Asking them open questions about their feelings on the surgery and what coping mechanisms they use will help you coordinate your care.Example Question:
How are you feeling about the surgery?
Finding:
Asked about coping with body changes
Finding:
Reports meeting with counselor
(Found)
Pro Tip: Patients undergoing surgery to amputate a limb are faced with a permanent loss. Asking them open questions about their feelings on the surgery and what coping mechanisms they use will help you coordinate your care.Example Question:
How are you coping with the changes to your body?
Finding:
Reports difficulty coping
(Found)
Pro Tip: Patients undergoing surgery to amputate a limb are faced with a permanent loss. Asking them open questions about their feelings on the surgery and what coping mechanisms they use will help you coordinate your care.Example Question:
How are you coping with the changes to your body?
Finding:
Asked about cultural or spiritual needs
Finding:
Denies current cultural or spiritual needs
(Found)
Pro Tip: Asking a patient an open question about any cultural or spiritual considerations helps you make decisions based on clinical judgement while being respectful of the patient’s culture and lifestyle.Example Question:
Do you have any spiritual needs I can assist with?
Past Medical History
Finding:
Asked about allergies
Finding:
Denies food allergies
(Available)
Pro Tip: Asking a patient to identify any allergies can prevent problems ranging from patient discomfort to more life-threatening reactions. Documenting these allergens and the patient response is important in coordinating care with members of the care team.Example Question:
Do you have any food allergies?
Finding:
Denies environmental allergies
(Available)
Pro Tip: Asking a patient to identify any allergies can prevent problems ranging from patient discomfort to more life-threatening reactions. Documenting these allergens and the patient response is important in coordinating care with members of the care team.Example Question:
Do you have any environmental allergies?
Finding:
Denies latex allergy
(Available)
Pro Tip: Asking a patient to identify any allergies can prevent problems ranging from patient discomfort to more life-threatening reactions. Documenting these allergens and the patient response is important in coordinating care with members of the care team.Example Question:
Are you allergic to latex?
Finding:
Denies medication allergies
(Available)
Pro Tip: Asking a patient to identify any allergies can prevent problems ranging from patient discomfort to more life-threatening reactions. Documenting these allergens and the patient response is important in coordinating care with members of the care team.Example Question:
Do you have any medication allergies?
Finding:
Asked about existing health conditions
Finding:
Reports coronary artery disease
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.Example Question:
Do you have any existing health conditions?
Finding:
Reports peripheral vascular disease
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.Example Question:
Do you have any existing health conditions?
Finding:
Reports diabetes
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.Example Question:
Do you have any existing health conditions?
Finding:
Asked about diabetes type
Finding:
Reports diabetes type 2
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventative and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.Example Question:
What type of diabetes do you have?
Finding:
Asked about chief complain
Finding:
Asked about diabetes management
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