Falls-
Yesterday I introduced an abbreviation important to falls MAE. Because I started with that abbreviation we're going to work backwards from the abbreviation and the after affects of a fall to the causes.
So the client is already on the floor. They've fallen. Too late to prevent the fall, cause it's happened. What needs to happen next.
For today the following scenario is going to be discussed:
Nurse heard patient calling out. Nurse went to room and found patient on the floor. Patient unable to tell nurse how patient ended up on the floor. Pt. MAE. Pt assisted back to bed and physician notified. NNO at this time.
What happened, or what happens:
The nurse heard the patient call out, she went into the room to check on the patient. The nurse asked the patient what happened. The nurse should have assessed the patient to ensure that the patient could move all extremities (MAE) within normal limits for the patient. It appears that she saw evidence of that, but did not necessarily assess for the ability to move all extremities. After she saw that the patient had not been visibly injured at this time, the patient was assisted back to bed.
This is a fairly straight forward version of what I see when a patient falls. There are a ton of things that could go wrong with this scenario, even in my little note. Using a Certified Legal Nurse Consultant can help identify those things.
Tuesday, September 29, 2015
Monday, September 28, 2015
Monday September 28, 2015 Abbreviations
Today we have a simple but important abbreviation. And as a result a short post. This abbreviation is especially important when clients fall. We'll discuss falls briefly tomorrow, and give a brief overview of some of the reasons that people fall.
Todays abbreviation is
MAE
MAE stands for moves all extremities. Extremities are limbs. Being able to move all extremities after a fall is important.
Examples
Pt. able to MAE.
The reason that there are not two examples is that is usually the only way that this particular abbreviation is used. Sometimes it is used in physical therapy notes but usually in the same context. Tune in tomorrow for more on falls.
Todays abbreviation is
MAE
MAE stands for moves all extremities. Extremities are limbs. Being able to move all extremities after a fall is important.
Examples
Pt. able to MAE.
The reason that there are not two examples is that is usually the only way that this particular abbreviation is used. Sometimes it is used in physical therapy notes but usually in the same context. Tune in tomorrow for more on falls.
Tuesday, September 22, 2015
Tuesday September 21 2015 SOB
First off, for my Jewish readers I hope that the fast tonight and tomorrow is easy and meaningful and to my Muslim readers a happy Eid Mubark.
Lets talk about SOB. Yesterday I related (poorly) a joke told to me by my father about a client who was demonstrating SOB (shortness of breath) and confused it with another meaning for the same abbreviation.
Shortness of breath is a big concern for medical staff and when patients are complaining of shortness of breath staff acts quickly. The causes are many and numerous. Shortness of breath can be caused by anything from a panic attack to a heart attack or stroke.
Not only is shortness of breath something a client can report feeling without measurable symptoms but it can also be measured. Clients experiencing shortness of breath may have decreased oxygen levels in their blood (measured with a small device placed over the finger, toe, or ear). Their respiratory rate is usually INCREASED, because they're trying to get more oxygen in, and they look uncomfortable.
The best way to resolve shortness of breath is to resolve the cause of it. If the patient is having a panic attack, applying oxygen may not help but giving Ativan and easing the symptoms may help, but if the patient is having a heart attack, oxygen will help. If the patient is experiencing an asthma attack medication to open the airway through inhalation will help.
In short- shortness of breath is a dangerous situation, and the cause needs to be diagnosed quickly to help guide treatment. It is not a cause, but is a symptom of a more serious medical condition, and should be treated with respect.
Lets talk about SOB. Yesterday I related (poorly) a joke told to me by my father about a client who was demonstrating SOB (shortness of breath) and confused it with another meaning for the same abbreviation.
Shortness of breath is a big concern for medical staff and when patients are complaining of shortness of breath staff acts quickly. The causes are many and numerous. Shortness of breath can be caused by anything from a panic attack to a heart attack or stroke.
Not only is shortness of breath something a client can report feeling without measurable symptoms but it can also be measured. Clients experiencing shortness of breath may have decreased oxygen levels in their blood (measured with a small device placed over the finger, toe, or ear). Their respiratory rate is usually INCREASED, because they're trying to get more oxygen in, and they look uncomfortable.
The best way to resolve shortness of breath is to resolve the cause of it. If the patient is having a panic attack, applying oxygen may not help but giving Ativan and easing the symptoms may help, but if the patient is having a heart attack, oxygen will help. If the patient is experiencing an asthma attack medication to open the airway through inhalation will help.
In short- shortness of breath is a dangerous situation, and the cause needs to be diagnosed quickly to help guide treatment. It is not a cause, but is a symptom of a more serious medical condition, and should be treated with respect.
Monday, September 21, 2015
Monday Sept 21, 2015 Abbreviations
A Joke: (badly told because I can only tell jokes badly)
There was a gentleman who became very sick. He headed to the local hospital and soon became critically ill. He began to recover, and as part of his recovery he began to review his medical records. As he was reviewing his medical records he quickly became concerned. His nurse came in. The gentleman apologized profusely to the nurse, and said I am so sorry for my behavior while I was sick. The nurse looked at him confused. The gentleman pointed to a spot in the medical records. The nurse laughed. SOB she said stands for Short of Breath.
Like I said a badly told joke.
But this week's abbreviation is
SOB
SOB stands for short of breath or shortness of breath. This is a pretty common abbreviation. It is seen in lots of places and tomorrow I'll discuss some of the common causes of SOB that are seen in the medical record.
Examples
Chief Complaint: SOB
Pt. appeared SOB with use of accessory muscles and rapid respiratory rate.
Tuesday, September 15, 2015
Tuesday September 14 2015 DVT
For the second topic that I want to add to the blog, I think we'll discuss various disease processes (which are just diseases) that are featured in the media.
My mom is the inspiration for this particular post. She was watching TV the other night when I wandered into the kitchen. I heard the end of a Xaralto commercial and she asked me about risk for DVT.
A DVT (deep vein thrombosis) is a type of blood clot. Everyone can get blood clots, and everyone can get DVT's. There are certain people who are more at risk for DVT's than others. People in situations where blood is more likely to stay in your legs (which is the most common site for DVT's) are more at risk than the general population. Some of those populations include people sitting on airplanes for long periods of time, women over 35 on birth control, and those with abnormal heart rhythms. These are the people that the advertisements for medication on TV are aimed at.
People in hospitals and nursing homes are also at risk for DVT's, but we know what to do to try and prevent DVT's. Its not a perfect science, but encouraging early mobility, the use of SCD (sequential compression devices) and medication (heparin) helps.
The medications advertised on TV (Xaralto, etc) are designed for active adults who are unlikely to suffer complications from bleeding. The way that all of the medications work (Xaralto, etc and Heparin and Warfarin) is by decreasing the clotting factor in the blood. The older medications (Heparin, Warfarin) can be reversed by administration of Vitamin K. The newer medications (Xaralto, etc.) can only be reversed by administration of Fresh Frozen Plasma or clotting factor.
This is the reason that all medication should be discussed with the prescribing physician including risk factors. Sometimes, the newest medication isn't always best for treating the disease.
DVT's are usually diagnosed when patients have pain in their calf along with warmth and redness. The patient undergoes a Doppler of the painful extremity, where like the weather radar, changes in the blood flow in the leg can seen. DVTs when treated quickly resolve without complications and patients can discontinue their medication. A DVT that goes untreated can kill. It "breaks free" from its location and can travel to the lungs where the blood vessels are much smaller. When the blood vessels in the lungs are blocked, it becomes difficult to breath, and if the blood clot is big enough, it unfortunately will kill the person. When the DVT "breaks free" and travels to the lungs it is called a pulmonary embolism and can constitute a medical emergency.
Please don't hesitate to contact your medical professional for more information, including diagnosis and treatment. Medical professionals are trained to diagnose and treat diseases. This is designed to be supplementary information ONLY!
My mom is the inspiration for this particular post. She was watching TV the other night when I wandered into the kitchen. I heard the end of a Xaralto commercial and she asked me about risk for DVT.
A DVT (deep vein thrombosis) is a type of blood clot. Everyone can get blood clots, and everyone can get DVT's. There are certain people who are more at risk for DVT's than others. People in situations where blood is more likely to stay in your legs (which is the most common site for DVT's) are more at risk than the general population. Some of those populations include people sitting on airplanes for long periods of time, women over 35 on birth control, and those with abnormal heart rhythms. These are the people that the advertisements for medication on TV are aimed at.
People in hospitals and nursing homes are also at risk for DVT's, but we know what to do to try and prevent DVT's. Its not a perfect science, but encouraging early mobility, the use of SCD (sequential compression devices) and medication (heparin) helps.
The medications advertised on TV (Xaralto, etc) are designed for active adults who are unlikely to suffer complications from bleeding. The way that all of the medications work (Xaralto, etc and Heparin and Warfarin) is by decreasing the clotting factor in the blood. The older medications (Heparin, Warfarin) can be reversed by administration of Vitamin K. The newer medications (Xaralto, etc.) can only be reversed by administration of Fresh Frozen Plasma or clotting factor.
This is the reason that all medication should be discussed with the prescribing physician including risk factors. Sometimes, the newest medication isn't always best for treating the disease.
DVT's are usually diagnosed when patients have pain in their calf along with warmth and redness. The patient undergoes a Doppler of the painful extremity, where like the weather radar, changes in the blood flow in the leg can seen. DVTs when treated quickly resolve without complications and patients can discontinue their medication. A DVT that goes untreated can kill. It "breaks free" from its location and can travel to the lungs where the blood vessels are much smaller. When the blood vessels in the lungs are blocked, it becomes difficult to breath, and if the blood clot is big enough, it unfortunately will kill the person. When the DVT "breaks free" and travels to the lungs it is called a pulmonary embolism and can constitute a medical emergency.
Please don't hesitate to contact your medical professional for more information, including diagnosis and treatment. Medical professionals are trained to diagnose and treat diseases. This is designed to be supplementary information ONLY!
Sunday, September 13, 2015
Sunday September 13, 2015 Holiday Tomorrow Abbreviation Today
We have one more abbreviation to cover in our short related abbreviations series. This, like many other abbreviations is difficult to produce in computer short hand, and that accounts for some of the variation in the way that it is written today in electronic documentation. This is the version I demonstrate below.
Here's this week's abbreviation:
2nd to
This abbreviation means related to or due to depending on the circumstance of the sentence structure. In electronic records it is written as 2nd or just 2. In handwritten text it is seen as 2 followed by the degree symbol (2º) Most people don't know that you can do that with simple computer commands and don't have the time to do it.
This is a much more common abbreviation for physicians to use than it is for nurses to use. This is also a common physical therapy abbreviation.
Examples
Client unable to ambulate 500 ft 2º complaints of shortness of breath and fatigue.
Final Diagnosis: Syncope 2nd to transient hypotension.
This means fainting due to a brief episode of low blood pressure.
Here's this week's abbreviation:
2nd to
This abbreviation means related to or due to depending on the circumstance of the sentence structure. In electronic records it is written as 2nd or just 2. In handwritten text it is seen as 2 followed by the degree symbol (2º) Most people don't know that you can do that with simple computer commands and don't have the time to do it.
This is a much more common abbreviation for physicians to use than it is for nurses to use. This is also a common physical therapy abbreviation.
Examples
Client unable to ambulate 500 ft 2º complaints of shortness of breath and fatigue.
Final Diagnosis: Syncope 2nd to transient hypotension.
This means fainting due to a brief episode of low blood pressure.
Sunday, September 6, 2015
Sunday September 6th. Holiday Tomorrow Abbreviation Today
Because tomorrow is the Labor Day Holiday in the US, I, like most of America will be taking the day off and avoiding labor. So I decided I'd post the weekly abbreviation today.
Last week I started out with the first in a series of abbreviations (r/t) that mean very similar things.
The next in this list of important abbreviations is as follows:
D/T-- due to
Like related to this particular abbreviation links together like objects. This focuses on cause and effect where related to is more likely to be used when things are less clearly linked.
Example
Pt had syncopal episode d/t transient hypotension. (Patient fainted due to a brief episode of low blood pressure).
Pressure ulcer worsened d/t lack of repositioning by staff in the previous week.
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