When a patient is admitted, one of our duties is to finish their admission assessment. As part of the admission evaluation, their medical and surgical histories, current home medications, allergies, vital signs, previous medications (including the reasons for discontinuation and side effects), history of suicide attempts, self-harming behaviors, presence of hallucinations, and more are gathered. Assessments are made on both subjective and objective results. The CIWA, COWS, AUDIT, and AIMS are a few tests that help nurses guide patient treatment. For this approach, some schizophrenic individuals are unreliable because they exhibit disorientation or bewilderment. Additionally, there are instances when they may downplay their symptoms or hide information from others that contradicts their chart.

Hypothetical Scenario

To gather this data for care direction, the electronic medical record is an essential tool. Informatics is used in EMRs, portal systems, and collection equipment such as EKG and vital sign machines. These technologies provide essential information for guiding the patient’s treatment strategy in addition to enabling data collection. In my hypothetical situation, let’s imagine that an actively psychotic patient with paranoid and grandiose delusions has been brought in from the emergency room. Due to a chaotic mental process, the patient is unable to provide a trustworthy medical history. The patient is returned to the unit once his items have been searched and his skin evaluated. The patient has previously experienced numerous inpatient hospitalizations, which you are aware of as the nurse who received the handoff report. In the past, he has used numerous psychotropic drugs, some of which have just been stopped. You are instructed to give the patient 5 mg of Zyprexa orally at bedtime. Additionally, the patient complains of pain, for which Tylenol PRN is given. You must return the patient to the emergency department after 15 minutes since they are experiencing an allergic response.

Data Usage, Collection, & Knowledge

In hospitals, inadequate communication during SBAR hand-off accounted for 60% of adverse events, according to the Joint Commission (Charles, 2021). The information obtained from the handoff report and the electronic medical chart could be utilized in this situation. Upon receiving the patient at their institution, the nurse needs to have asked more precise questions regarding the medications the patient had previously taken. This covers the reasons they could have been stopped, which can occasionally be attributed to a negative drug reaction. The side effects of psychotropic drugs include Steven Johnson Syndrome, neuroleptic malignant syndrome, tardive dyskinesia, and dystonia. By entering the patient’s full name, date of birth, and MRN number into the EMR, the nurse can quickly access the patient’s medical data. His scheduled Zyprexa was stopped due to an allergic reaction he experienced two weeks prior, the nurse found when reviewing the electronic medical record for data collection. He was previously taking Abilify, but it was stopped because of a negative drug reaction, the nurse also learns. By adding these drugs to his EMR’s allergy tab, the nurse can now make use of the information gleaned from this data. This covers reaction type, medicine name, and severity type. Additionally, informing the medical staff if they attempt to prescribe these prescriptions for the patient in the future, will stop events from happening again. A warning will also appear for nurses when these drugs’ barcodes are scanned by EPIC. Given that the patient’s AST and ALT values were elevated, an alternative medication order should have been acquired and Tylenol should not have been given for his discomfort.

A Nurse Leader’s Improvement Process

At my present job, we have also encountered circumstances quite comparable to these. Together, with the help of our nurse leader, we developed strategies to stop these occurrences from happening in the future by applying our clinical judgment and reasoning. We created a comprehensive report form that our facility’s nurses are expected to complete upon receiving the handoff report. Home prescriptions, medications used within the last 12 hours, allergies, the cause for admission, commitment status, vital signs, previous medical and psychological history, abnormal lab results, UDS results, drug and tobacco usage, and more are all included in this. Receiving hand-off reports in a comparable organized manner (SBAR) has been demonstrated to improve patient safety and care by reducing communication errors between the two facilities.

Since they can find important information that hasn’t been disclosed, nurses are also obligated to study the patient’s medical chart before arriving (Jessee, 2021). Additionally, we have a policy that requires that aberrant test results be reported right away to the doctor. Because blood work is taken in the mornings and evenings as needed at my institution, the nurse must evaluate lab results at the end of each shift. One of the standard orders that our facility’s clinicians have for our patients is a PRN Tylenol medication. Even when the patient has increased liver enzymes, the clinician may still prescribe Tylenol to substance addiction patients.

References

Charles, C. N. (2021). How registered nurses develop their clinical judgment skills during their careers (Doctoral dissertation, Northcentral University).https://www.proquest.com/openview/7ceafca5a97d729ff8ab39c854082f01/1?pq-origsite=gscholar&cbl=18750&diss=y

Jessee, M. A. (2021). An update on clinical judgment in nursing and implications for education, practice, and regulation. Journal of Nursing Regulation, 12(3), 50-60.https://www.sciencedirect.com/science/article/abs/pii/S2155825621001162