Essential Nursing Procedures and Clinical Documentation
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Documentation and Physician Orders
Recall and Documentation: When giving a report, include the patient's condition, changes within the last 24 hours, abnormal laboratory results, recent vital signs, medications, new orders, and tasks for the next shift.
Transcribing Physician Orders: Ensure the inclusion of the date, time, signature, and accuracy. Verbal Orders: These are permitted only in emergencies. You must read back the order to the physician. It must be signed later, typically within 24 hours.
Heparin Administration and Monitoring
Action: Heparin blocks the conversion of fibrins and acts as an anticoagulant to prevent blood clot formation; it prolongs clotting time. It can be administered as a bolus or via IV. The minimum bolus rate is 25... Continue reading "Essential Nursing Procedures and Clinical Documentation" »