INSTRUCTIONS FROM TEACHER:
The student will select a patient in the clinical setting to perform the safety assessment (with the instructor’s permission). The student will identify, and address factors related to patient safety, followed by a plan to address the identified concerns.
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Assignment Objectives The student will:
1.Recognize the importance of individual factors that may put the patient at risk for injury. 2.Assess factors that may put an individual patient at risk for injury and harm.
- Develop a plan of care to keep the individual client safe, including effective elements in the current plan of care.
– This is a link to someone’s paper that I found online for you to see how it should be and the wording of it.
These are the topics to cover:
- Environment
- Susceptibility to violence
- Fall Risk Assessment
- Braden Scale
- Mini Mental
- I did the yellow part on my own I will add in a pictures so you can see on the bottom of this doc the pt passed all the exams
- Substance Abuse
- He doesn’t drink alcohol ever so you can write that but make it a bit more wordy
- Ability to Perform ADLs
- Barriers to Medication and Safety Compliance
- Vision and Hearing Deficits
- Safety Risk
Notes on the Patient
Start the paper with the sentence: On Tuesday, September 12th, 2024 a safety assessment was conducted on GC, a 68 year old male who was admitted to Englewood hospital in New Jersey.
We can’t write the patient’s name so we will use his initials: GC
You can organized this based on the topics to cover I am just writing you the notes that I have
- He is 5’7 and caucasian
- Pt is Awake, alert, and oriented x4
- His skin: upper body skin is mostly intact. Lower legs slight skin breakdown, feet discoloration were purple/ gray and his legs were spotty brown due to his
Diabetes Mellitus
- His feet were cold/ capillary refill was good. Toe nails were thicker from the diabetes limited hair growth on legs which is a sign of low circulation. He had a cabbage bypass and the vein was taken from his leg. He does visit his doctors regularly to make sure everything is up to date.
- Eyes: he sees his eye doctor annually and knows that he has to because of his diabetes. His vision is stable and hasn’t changed
- Chest: His chest is even, no discoloration, no lesions, scar from his cabbage graft bypass approximated good with no keloids, even hair distribution. Heart sounds were normal.
- Abdomen: Palpation and percussion on abdomen were good → no pain upon palpation or percussion. Active bowel sounds in all 4 quadrants
- Musculoskeletal:
- Hand strength equal and bilateral
- Leg strength: his left leg is 4+ and his right leg is 5+
- He has a healed sore on his right thigh
- He has an altered range of motion in his left middle finger because of his job he used to type a lot for work → he has nodules and a barsads nod. SOmetimes at night he pressed his finger with a band and says that it helps him
- He has watery stool bowel movements 11 times a day in preparation for his colonoscopy
- He has a history of smoking cigarettes
- He is up to date on his vaccines
- Info for elderly abuse: He says that he is not abused and he feels comfortable in his home his lives alone with his wife. He lives in a two family home and rents so he feels comfortable because there are people close by
- He lives in a safe area with his wife
- His fire extinguishers are up to date
- He has never fallen down the stairs of his home
- When I did thi assessment he received two platelet transfusions
- He states that his sister is a nurse so he is very well educated
- He takes his medications on time and when it is needed. If his blood pressure is within normal range he states that he will not take his medication.
- He has no known allergies
- He is a full code status
- He came in to the hospital for: THrombocytopenia
- He is prone to bleeding
- He had no injuries on his job worked in manufacturing for 42 years
- No violence in his home
- He takes supplements:
- Vitamins B12, and Iron
- No drug use
- He goes to church with his wife and online mass
You also have to add in something you would teach the pt so “whne the patient goes home I would suggest” (ex: a patient will continue to see his eye dr) you have to add a couple of these
He has:
- Diabetes mellitus
- Coronary artery diease
- Esophageal varices without bleeding HCC chronic
This is the rubric for the safety assessment (this assignment):
