What Should the Nurse Do?
1
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If a nurse maintains records that are incomplete, vague, and just generally do not make sense, this gives the impression they are not invested in the patient’s care or their safety. What can the nurse do to provide patient-centered care and ensure the records are written following the American Nurses Association guidelines?
Stacy is a young adult with a history of many childhood allergies, including grass, trees, and animal dander. She is currently spending the summer at her grandparents’ lake house before starting college this upcoming semester. Stacy has been experiencing a runny nose and itchy eyes since arriving at the lake house. She approaches her grandmother to inform her she was stung by a bee while fishing on the dock with her grandfather. Stacy feels too bad to drive and asks her grandmother to take her to a local clinic. You are a nurse working in the Family Practice Clinic when Stacy comes in with her grandmother for an evaluation. The grandmother says Stacy has already taken Benadryl 25 mg by mouth and rubbed hydrocortisone cream on the insect bite. As a nurse, it is important you take an accurate history regarding Stacy’s previous reactions to insect bites. Your clinic is part of a larger hospital system, and you can access Stacy’s EHR from her normal primary care physician’s office in the city where she resides. You determine she has a previously documented history of an allergic reaction to a bee sting three years ago.
2
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What other information might the nurse need to detail regarding the previous reaction?
3
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Stacy is over age 18 years, so she is of the legal age of majority and can be responsible for answering medical questions and making her own medical decisions. However, the grandmother wants to be in the room while care is delivered. What should the nurse do?