Fundies Test 2
Card Set Information
Fundies Test 2
Fundies Test Review
What is documentation?
The written or typed, legal record of all pertinent interactions with the patient.
What is a Kardex?
A summary of information
What are soap notes and who uses this format?
A format of documentation used by most physicians
Are consults part of the medical record?
Are physicians orders part of the medical record?
Which part of an xray report is important?
the impression isthe important piece
What kind of graphs are important in medical records?
Graphs that show trends
When are I&Os documented?
every 8 hrs unless specified
What are all of the components of a medical record?
Plan of care
Nursing admission assessment
Client education record
What is the mechanism for PRO review?
Should you always document the results of intervention?
What are the elements of effective documentation?
Ensure you have the correct chart
Sign each entry with name and credentials
Make early first entries on your shift
Chart at least every 2 hours
Document all telephone calls related to clients case
Chart client resonse to meds
Chart precautions or preventative measurses
Data from visits by physicians
Refusal of treatment
NA for info that doesnt apply
Chart often enough to tell whole story
Discharge, referrals, patient teaching
date and time
What should you always do with calls to physicians?
What else should be charted when charting a symptom?
What you did about it
How should errors in charting be fixed?
cross out with oneline, write mistaken entry, and initial
What type of offense is altering a record?
a criminal offense
What is in a change of shift report?
Basic identifiying information and current diagnosis
Current appraisal of patients health status
Summary of each newly admitted patient
Report on patients who've been transferred or discharged
What is included in a transfer within an institution?
What is included in telephone reports?
Self, pt, and relationship to pt
concise and accurate changes in pt condition of concern and resonse to condition
current vitals and clinical manisfestations
havepts record at hand
record time, date of call, what was communicated, physicians response
What do you needfor client admission?
Authorization from a physician for treatment
On client admissiong what should be the nurses activities?
Prepare clients room
orientate client to area
safeguard valuables and clothing
compile nursing data base
nursing care plan
On cliet discharge, what are the nurse's responsibilities?
obtain a written medical order
provide discharge instructions
notify pertinent departments
write discharge summary
If a patient leaves against medical advice, what will happen and what should the nurse do?
Insurance won't pay, and the nurse should explain the procedure if the pt wont sign
What should the nurse do in the event of a client transfer?
inform client and family for need of transfer
communicate with agency or unit to be transferred to
photocopy medical record and send with client or fax ahead
collect client's belongings
accompany ems or paramedics if necessary
assist with transfer to stretcher
What has research shown about medical errors?
Disasters result largely from failures in design and organization that can cause operator errors. Bad systems lead to problems with patient safety
What does PDSA stand for?
plan, do , study, act
what is an incident report?
an agency recordofan accident or near miss
Who is at risk for falls?
65 and older
hx of falls
altered gait or posture
: diurectics, sedatives, hypnotics, analgesics
slow reaction time
Why are many falls unreported?
pt fears independence loss
What is included in the assessment for fall prevention?
ability to ambulate and transfer
What are some inpatient methods used to prevent falls?
non skid socks
bed in lowest position
bed side commode
call light in reach
walking aids in reach
ableto reach any needs
wheelchair wheels locked
respond to call lights
What are some in home fall preventions?
telephone in reach
hand held grabbers
communicate high riskto neighbors
good kitchen ventilation to prevent glasses fogging
lights on steps
light switch placement
non slipfloor in tubs
clear all pathways
What are the two types of restraints?
chemical and physical
What are some purposes that restraints are used for?
Reduce risk of injury from falls
Preven interuption of therapy
: ivs, catheter
Prevent confused or agitated pt from removing life support
reduce risk of injury to others by agitated client
What is required in order for a restraint to be used?
A written order is required
When are restraint orders updated?
every 24 hrs
Can you put restraints on a patient before an order?
Yes, pt safety comes first. Just be sure to get an order asap.
When is it ok to use restraints?
When all other methods have been exhausted
How often should patients in restraints be checked on?
Every 15 min
What needs to be done when checking on a pt in restraints?
Assess and document condition of pt
: skin and circulation
Reposition the pt
Assist with toileting and offer fluids
Reassess need for restraints
What could you do to prevent the use of restraints?
encourage family/friends to stay with pt
keep confused pts near nursing station
use diversionary activities
maintain frequent toileting routine
reposition and ambulate frequently
use relaxation techniques
What should you do in the even of pt poisoning?
Treat the pt first and then the poison.
What are some common S&S of accidental poisoning?
change in appearance/behavior
burns, blisters, suspicious odor in mouth
longer naps than usual
What are the secondary steps in poison control?
Identify the poison
time and amount ingested
save any vomitus
call poison control center
What are the tests used in diagnostics?
Urine and serum analysis
CAT scan, EEG
What is the guideline to follow in disaster planning?
Do the greatest good for the greatest number of people
Which pts have the most priority in diaster planning?
resources should be used for pts with the strongest possibility of survival
What is included in disaster planning?
notification and communication of disaster
all available staff required to report
use of diagnostic procedures limited
use of hospital resources determined by designated med officer
areas of hospital used as needed for treatment
person designated to deal with media and traffic control
What are the nurse's responsibilities in diasaster planning?
assess nursing unit for resources
assess current clients for discharge
activate staff recall plan
communicate with hospital disaster control center
What are the levels are triage in disaster planning?
: unstable, need immediate care to save
: stable, can wait 30-60 min
: stable, can wait longer
: unstable and probably fatal
: dead on admission
What are the interventions in disaster planning?
render first aid
care standardized to standing orders (dont need phys order)
expanded nursing responsibilities
emotional and spiritual care to pts and families
Evaluation of diaster planning includes what?
have clients been cared for in orderly fashion?
have client's physical needs been met?