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99 Cards in this Set
- Front
- Back
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Where are lab reports stored when patient is discharged?
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in chart
new lab reports are put ON TOP of old lab reports |
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Who can add information to a transfer summary?
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nurse, dr or dr assistant can add information to the transfer summary
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Where is a transfer summary kept?
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usually in a file cabinet until the client is transferred. It goes with the client to the new instituion. Start filling it out right away when you know a client will be transferred because it takes a long time to fill out.
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How many types of history and physical forms are found in the patient chart?
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many. one medical (dr) and one nursing. They are kept in the file on discharge
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Who fills in graphic sheets?
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NA, nurse or unit clerk
any nursing personnel can add information to them they are kept in client chart or at bedside |
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What is noting the order?
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when a nurse looks over the PO and checks the unit clerk's work for accuracy
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Who can add information to the nursing notes?
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any nurse can add info but the majority of the info comes from the nurse providing care for the client
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Where is the Kardex found?
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in notebook or at nursing station
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Where does Kardex go upon d/c?
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in garbage. it is not part of permanent record
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Who can add information to the discharge instruction?
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physician
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Where does discharge instruction sheet go upon d/c?
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one copy to client
one copy to physician one copy to chart |
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What is an operative report?
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A report that is created after a procedure or surgery. It describes how the client tolerated the procedure. It is then sent to the nursing unit.
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Who can add to the operative report?
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only the person who dictated it
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What report describes the response or lack of response to treatment?
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the physicians progress notes
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Who can fill out a consultation form?
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nurse, doctor..any person who provides consultation to the client case fills out these forms.
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Who can add to a consultation form?
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only the person who originally filled them out. No one else can alter them.
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Where are consultation forms kept upon discharge?
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in the client's chart
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What is a face sheet?
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form filled out before the client is admitted to the hospital...done by the admitting department.
contains demographic information about client |
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hemoptysis
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spitting up blood from lungs
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pallor
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without color
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profuse sweating
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diaphoresis
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all inclusive bath
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complete bath
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thin/undernourished
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emaciated
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"I am mad" is the patient statement. What is the behavior observed?
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loud and belligerent, frown on face, vigorous movements
make sure you chart both |
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sudden spasm or convulsion
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paroxysm
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Stool that remains its shape
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formed
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Stool or mucus that is thick, sticky, gluelike
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tenacious
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spasms marked by muscular rigidity and relaxation
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clonic spasm
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convulsion that is persistant, involuntary muscle contraction
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tonic spasm
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sudden spasm or convulsion
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paroxysm
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no response, no reflexes
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comatose
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sleeps often, arouses easily
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lethargic
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sleeps often, arouses with vigorous stimulation
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obtunded
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responds to pain with purposeful movement
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stuporous
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responds to pain with decerebrate/decorticate posturing
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semicomatose
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Emesis ejected distally
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projectile
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slightly blood emesis
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blood-tinged
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grossly bloody emesis
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hematemesis
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agent given to induce vomiting
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emetic
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Agent given to STOP vomiting
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anti-emetic
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Spitting up blood from lungs
(filed under EXPECTORATION) |
hemoptysis
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Face or skin broken out
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presence of rash, acne
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Face or skin black and blue
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bruise, ecchymosis
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Without a fever
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afebrile
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Elevated temperature suddenly returning to normal
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crisis
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Elevated temperature gradually returning to normal
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lysis
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Lips with tiny cracks
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fissured, cracked
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A group of symptoms
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syndrome
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Torn skin
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lacerated
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Raw surface on skin
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excoriation
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Irregular heart rhythm
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arrhythmia, dysrhythmia
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Pain that comes and goes
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paroxysmal, spasmodic, intermittent
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Arrythmia
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irregular heart rhythm
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Dysrhythmia
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irregular heart rhythm
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Paroxysmal
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pain that comes and goes
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Nourishment given via tube
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gavage
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Normal breathing
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Eupnea
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Absence of respiration....they are not breathing
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Apnea
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Patient is snoring
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stertorous
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Patient is suffocating
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asphyxia
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Each entry made in a chart, should have these things:
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-Day
-Month -Year -Hour |
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What should be charted?
O A M I |
observations
assessments medications interventions |
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Other than crossing out an error in the chart with a single black line, what else do you need to do to the entry?
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initials
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At least once on each round, you should make sure you sign the chart like this.....
(maybe the first time you see a chart) |
A full signature and title should appear at least once on each record
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What is the punctuation situation with the charting?
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Each entry should begin with a capital letter to separate sentences, ideas or phrases.
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Hut Hut! Make sure you use this type of time.
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Military Time
1200 1300 1:00 1400 2:00 1500 3:00 1600 4:00 1700 5:00 1800 6:00 1900 7:00 2000 8:00 2100 9:00 2200 10:00 2300 11:00 |
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What should be on each page of the chart?
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client's full name
hospital number hospital label |
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Who can see the record?
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It is the property of the agency. Consent must be obtained for anyone other than the client to see the record.
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Quality documentation is....
1 2 3 4 5 6 |
Factual
Accurate Complete Current Organized Legibile |
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In general, when teaching an infant, what is the best way to teach?
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through environment:
expose to textures interact with environment keep routines consistent |
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Why do you hold a baby firmly while talking to it softly and smiling?
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because you are a normal person and sometimes this frickin class disects everything into science and it just wants to make you SCREAM!
-to convey a sense of trust |
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What should you use to teach a toddler?
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play....
dolls, stuffed animals, toys (putting bandaid on toy), picture books, videos, simple words and short session <10 minutes |
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What should you incorporate into the teach of a preschooler?
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play...
role play, imitation, play to make it fun Keep it simple, through pictures and stories. Let them handle the equipment, use stickers, rubber stamps to reward learning. Keep it short <10 minutes |
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In what way do school age children learn?
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through information
show cause and effects answer questions fast & honest tell truth teach psychomotor skills needed to maintain health Keep it under 20 minutes |
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An adolescent has this focus while learning....
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values, social trusting relationships
privacy is essential be honest and truthful let them have as much control as possible |
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What is the focus of your teaching when you are instructing a young or middle age adult?
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independence
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What is an important task that would encourage participation in the teaching plan of a young or middle aged adult?
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setting mutual goals (independence - make your goals THEIR goals)
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How should you present the information to a young adult or middle aged adult in order for them to grasp it?
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present information in a way that they can relate it to their specific situation (independence)
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What is the focus of educating an older adult?
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Make it simple
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What type of environment is important for the older adult?
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quiet, brightly lit, facing them
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What type of visual aids should you use for older adults?
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primary colors, large well spaced letters
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What should you leave with an older adult after a teaching session?
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a written summary of the teaching session
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During the planning phase of client teaching, what are your three tasks?
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prioritize learning needs
develop teaching plan determine outcomes/goals |
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While you are teaching during the implementation phase, what is your first priority?
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meet the client's basic needs first
prepare environment present info in organized manner allow time for psychomotor skill practice Documentation |
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What information do you document in regard to teaching?
(done during implementation phase) |
What was taught
Goals met? Who was there People's response to teaching Questions/Concerns they raised Need for reevaluation/additional teaching or alternate teaching |
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When in the evaluation stage of the nursing process while client teaching, what four questions do you ask?
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Were goals met?
What data supports that goals were met? Was teaching plan effective? Does teaching plan need to be revised/modified? |
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What are the good things you assess for in the client(during assessment phase of nursing process) for client teaching?
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client readiness to learn
client ability to learn client's current knowledge |
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What are the bad things you assess for of the client(during assessment phase of nursing process) for client teaching?
Things that might inhibit learning |
barriers
physical barriers (pain, tremors) emotional barriers (anxiety, fear, depression) communication barriers (visual, hearing, speech) |
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What phase do you prioritize the things you need to teach?
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planning
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What phase do you define the learning need?
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nursing diagnoses
Knowledge Deficit: Wound Care Post Discharge |
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What phase do you figure out what materials to use for your teaching?
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planning
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What phase do you find support groups to help you?
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assessment
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What are the three domains of learning?
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cognitive
psychomotor affective |
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Accept, Acknowledge, Praise, Question
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Affective
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Answer, Choose, Define, Describe, Verbalize, Write
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cognitive
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Score, Select, Summarize, Relate, Repeat
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cognitive
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Administer, Ambulate, Prepare, Organize, Start, Use
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psychomotor
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Do, Operate, Assist, Arrange
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psychomotor
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In your nursing care plan where do you describe creating the environment for learning?
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planning
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