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Discussions
1
Two of the seven crucial conversations that healthcare professionals struggle with that contribute to patient harm and unacceptable error rates that I have noticed are broken rules and incompetence. I have seen nurses deliberately neglect to follow protocol because they did not think it necessary or were rushed to do something else and did not want to take the time to do the procedure correctly. I have also seen nurses who did not know the standards of care they should have known and did not exercise these standards when dealing with patients. They also demonstrated an inability to critically think about situations and lacked an awareness of certain subjects.
What I can do to deter these issues is to alert the head nurse so that we can all have a conversation about it, about why it is important to follow protocol and why it is necessary that nurses have their expected competencies and be able to practice at a high standard. I would even suggest that it be mandatory for all nurses to engage in continuing education. I would also suggest that nurses engage in the peer-review so that we can better police ourselves.
2
SOAP Note
Patient Information: MG, 38, FM
S.
CC (chief complaint): feel gassy at night, wake up with abdominal pain
HPI: 38 year old female MG
Location: abdomen
Onset: years ago
Character: gassy, cramps after lying down at night
Associated signs and symptoms: irritable bowel
Timing: bothersome especially at night
Exacerbating/relieving factors: propping sides up with pillows, colon cleansing tea
Severity: 5/10
Current Medications: none
Allergies: none
PMHx: none
Soc Hx: does not exercise, drinks alcohol moderately every night
Fam Hx: IBS on mothers side of family
ROS:
HEENT: Eyes: No visual...…that the pregnant woman should be made to feel comfortable and not be asked to move into position for examination until the time is required, while the adult patient can be asked to wait in position for examination while the physician gets ready to come in.
One common diagnosis for the pregnant woman would be gestational diabetes, which would be diagnosed by examining the blood sugar content through blood work testing that is regularly conducted. One common diagnosis for the older adult would be type 2 diabetes that is diagnosed through blood work as well.
One less common diagnosis would be ectopic pregnancy which would be diagnosed by way of ultrasound, which shows the fetus developing outside the sac. One less common diagnosis for the older adult would be macular degeneration which would be diagnosed by eye…
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