Need Response to below DQ with 1 scholary source 75 words.
Nursing Background
By M. Gray
The first issue within the case study was Annie Lewis providing a urine specimen to the advanced Practice Registered Nurse without proper labels or identifiers. Annie Lewis made no complaint of dysuria yet found the information in her electronic medical record. The second issue was the antibiotic prescription being ready, yet Annie feeling as though this may have been her beta blocker that had in fact been ordered early (Milstead, 2016, p. 240). Without the nursing background, Annie would have first questioned what dysuria was. I have had many patients that would have never understood the term dysuria. According to Graham and Brookey (2008), any written material or information should be in a manner the patient can understand, such as simple words and avoid medical terminology. Electronic patient files removes the face to face communication to ensure the patient understands the diagnosis, treatment, and medications to be taken and how often. The lab results showing a urinary tract infection would have went unnoticed to the untrained individual. When the call came in from pharmacy that the medication was ready to be picked up, a majority of patients would have assumed it was the beta blocker and waited to pick the medication up until needed. For Annie, she was aware that she had a urinary tract infection and knew enough to call the pharmacy and inquire what medications were ready for pick up. Annie had no signs or symptoms of the urinary tract infection and had she not had the knowledge to interpret lab results, the outcome could have been detrimental. An untreated urinary tract infection could potentially lead to sepsis (Sepsis Alliance, 2018, para. 2). World wide, those who have an untreated urinary tract infection which leads to sepsis, one third of them die (Sepsis Alliance, 2018, para. 4).

Breakdown in Communication
Communication is key during the patient care process to avoid adverse events. The first missed opportunity was collecting the urine specimen. The chain of command should have been followed to ensure that was in fact the patients urine specimen and proper labeling and patient identifiers should have been on the specimen cup. Most labs reject specimens without proper labeling. When updating the patient chart and entering a chief complaint of dysuria and receiving the lab results indicating a urinary tract infection, the patient should have been notified of the lab results and informed a prescription would be called in for an antibiotic. This is the time to utilize the teach back method for medication education. Communicate with the patient the need for the medication, how to properly take it, and ask for the patient to repeat back the education to ensure they understand the education. Beings this communication did not take place, someone without nursing knowledge could have ignored the phone call and left the urinary tract infection untreated and the patient condition could have worsened to the point they became septic.
Stage 2
According to HealthIT (2014), the requirements are “Improve Quality, Safety, Efficiency, Engage Patients & Families, Improve Care Coordination, Improve Public & Population Health, and Ensure Privacy & Security for Personal Health Information”. While their were major communication issues that could have led to a negative patient outcome, the Advanced Practice Registered Nurse’s office met the requirements of stage 2. The electronic health record was accessible to the patient and provided all the required information. The face to face or phone communication for follow information is where the office was lacking.
References
Graham, S. and Brookey, J. (2008). Do patients understand, The Permanente
Journal, 12(3): 67–69.
HealthIT. (2014). Achieve meaningful use stage 2, Retrieved from
https://www.healthit.gov/providers-professionals/s…
-meaningful-use-stage-2
Milstead, J. A. (2016). Health policy and politics: a nurses guide. Burlington, MA:
Jones & Bartlett Learning.
Sepsis Alliance. (2018). Sepsis and urinary tract infections, Retrieved from
https://www.sepsis.org/sepsis-and/urinary-tract-in…

 

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