As a nurse, you are the first member of the hospital’s healthcare team that Stefani encounters. You are responsible for obtaining and recording Stefani’s vital signs: weight, height, medications and medical history. You also are responsible for electronically charting Stefani’s medical information and keeping it current during her stay. Using Stefani’s EHR and Internet research, answer the questions and be prepared to discuss the responses with the rest of Stefani’s healthcare team.

  1. Review Stefani’s Inpatient EHR: The oncologist has ordered additional blood work for Stefani and the results are shown as normal or abnormal in her EHR. Identify which tests are abnormal and explain how this is indicated.

    Internet Research: Explain how these tests help the team determine Stefani’s diagnosis?

  2. Internet Research: A sentinel node biopsy and PET scan are performed on Stefani to help determine if and how far her cancer has metastasized. Provide a brief description of these procedures.

  3. Review Stefani’s EHR: What areas of concern do you see on Stefani’s EHR?

View Stefani’s EHR – Inpatient Chart