Unit 8 Clinical Notes

O/ECVS P80

Ht not enlarged Ht sounds normal

BP 130/90 RS NAD Abd Slight epigastric tenderness CNS NAD No enlarged lymph nodes Breasts Normal …

Sample 1

O/E Healthy womanCVS P 88- regularHt not enlargedHt soundsBP 120/70ChestAS near full term uterus.Tongue pale Neck—soft and slightly enlarged thyroid.

No bruit. No tremor. Hands warm and dryCNS ReflexesNo eye signsDiagnosis? Anemia

Sample 2

Session 2 Practical ReadingPassage 1

“Contemporary nursing requires that the nurse possess knowledge and skills in a variety of areas.”

nursing n.e.g. advertising engineering

a variety of

e.g. Computer science has been used in a variety of medical research.

“As care giver, the nurse is engaged in the holistic care needs of the patient, … . ”

“To provide effective care, the nurse uses decision-making skills … .“

to be engaged (in sth.)e.g. Dr. Bai has been ever engaged in psychotherapy research since 1990. Please call later, Dr. Bai is now engaged.

e.g. policy-making people care-providing nurse

n. – v.-ing

another n.

“As managers, nurses coordinate and delegate care responsibilities … .”

e.g. She works to coordinate all the first-aid stations in the area. You need to delegate some of the responsibilities to other nurses so as to have the job done collectively and successfully.

“Rehabilitation is the process by which individuals return to maximal levels of functioning after illness, accidents, other disabling events.”

e.g. Palpation is a kind of examination by which any deformity or abnormalities within the body is outlined.The department offers over 50 different courses, many of which are delivered by well-known professors.

disabling eventse.g. interesting story/surprising news

“As comforters, nurses should help the patient reach therapeutic goals rather than encourage emotional or physical dependence.”

e.g. A head nurse is expected to delegate responsibilities to other nurses rather than carrying them all out herself.

“As teacher, the nurse explains to the patients concepts and facts about health, demonstrates procedures such as self-care activities.”

W: Nurse is expected to perform many different duties such as she should lead patients to complete some self-care activities.

R: Nurse is expected to perform many different duties, for example, she should lead patients to complete some self-care activities.

T or F

2. The nurse functions as a manager in the way that she provides the whole care needs for the patient.

the whole care needs

(F)

manager coordinate, delegate, supervise

care giver

Passage 2 (pgs.88-89)

“It was used to describe a way-station where travelers, pilgrims, and ill people could stop and depend on receiving human care. ”

way-station e.g. way-side inn; way-out

where (Clau.)e.g. They will to fly to Kuming where they plan to attend the conference on History of Hospice.

“She founded St. Christopher’s hospice in London in 1967, which represents the beginning of today’s hospices in the world.”

St. Christopher’s hospice

Saint

Greenspire St.Street

, which (Clau.)

e.g. The operation was postponed, which was exactly what we wanted.

“The patient and the family together are considered the unit of care.”

“Follow-up bereavement services for the family after patient’s death.”

e.g. target of blame

e.g. After the a job interview a follow-up telephone interview of the former employer is usually done for more information of the applicant.

“The offerings from hospices can make patient’s last days as comfortable, peaceful and meaningful as possible.”

as adj. as possible

e.g. Please send back a reply as soon as possible.

Things which are given with a good will.

T or F (p.90)

5. To run a hospice is a good business.(F)

Most hospices in western countries are private, non-profit organizations.