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Clinician Role: (1.2, 1.4, 1.21)When conducting a Head To Toe Assessment, describe the type of findings that would indicate the nurse should stop their systems assessment and implement immediate interventions?You arrive to a night shift on a busy neurosurgery unit to find that your shift is short-staffed. Instead of having your typical assignment of 4 patients overnight, you are assigned 6 patients. They include2 patients who have just returned from the OR today (post craniotomy)1 patient transferred this morning from the neuro ICU to your unit (suffered a near fatal subarachnoid hemorrhage 4 days ago)1 patient who is bed-spaced from the neurology unit undergoing investigation for new onset seizures2 patients who have had spinal fusion surgery in the last 24-48 hoursYou realize that it will take an extended period of time to do full head to toe assessments on all of your patients. As you review your assignment in the nursing, how would you plan to begin your assessments? In what order would you check your patients? How would you approach determining your decision-making regarding head-to-toe assessments, focused assessments, and general surveys?Professional Role (2.1) [accept responsibility and seek assistance as necessary with decisions and actions within their legislated scope of practice]
ANDCommunicator Role (3.7, 3.8) [Communicates effectively in complex and rapidly changing situations; documents and reports clearly, concisely, accurately, and in a timeline manner]3. According to the College of Nurses of Ontario, “Communicating a diagnosis is a controlled act. An RN or RPN cannot communicate a diagnosis to a patient or their representative unless a physician or an NP delegates that act to you”.Within this context, consider:· Simulation 3 (Jack Spratt, experiencing sudden chest pain and shortness of breath.” In providing a verbal ISBAR (Identify-Situation-Background-Assessment-Recommendation) report to the physician, the RN’s communication of her assessment happens in the presence of the patient. She indicates that she believes he has suffered a spontaneous pneumothorax.· Simulation 2 (Janice Smith, post-operative for total hysterectomy, onset of new left facial droop, slurred speech, arm weakness. In providing a telephone ISBAR report to the physician, the RN’s communication of her assessment via telephone happens in front of the patient and her partner after they have asked her not to leave. She indicates she believes the patient is experiencing stroke-like symptoms.
Review the RN standards of practice within Ontario and determine if you believe this communication is appropriate or should be modified and provide a justification for your decision. If it should be modified, provide an alternative.
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