CDC 4N0X1 B Vol. 2- Patient Care Skills II Flashcards

Physician
Terms Definitions
Which healthcare providers in the Air Force medical facilities are authorized to both treat and admit pt's?
Dentists, physicians, and Certified nurising midwives
Who is responsible for notifying the inpatient unit that a routine pt is being admitted?
The physician or the physician's designated representative
What is the basic difference between a routine admission and a direct or newborn admission?
The order in which various procedures are carried out
What two factors determine where the pt goes after finishing with the admissions and dispositions office?
the condition of the pt, and facility policy
Whare are two advantages of preadmissions?
it cuts down on both pt waiting time and frustration
When should you begin to assemble the inpatient record?
immmediately following notification that you are getting a pt
What are your responsibilities concerning the inpatient record when there are no 4A's assigned to your floor?
you need to know what paperwork is required and how to fill it out
What items whould you bring to the bedside of a newly admitted pt?
bed pan, urinal, gown, slippers, water pitcher, cup, wash cltoh, wash basin, emesis basin, and if necessary...IV pole and urine specimen cup
Normally what admission procedures are done by the admissions nurse and tech?
pt assessment, pt history, VS, height and weight
Where should you place the call bell?
Attached to the bed within reach of the pt
What info should you cover when orienting the pt and family to your unit?
Visiting hours, day room rules, meal times, bathrooms, call bells, VS times, names of care providers, sign in and sign out procedures
What aspects of inpatient unit routines should you explain to the pt?
anything that affects the pt
What two methods are used in inpatient units to help monitor the location of pt's
pt status board, sign out log
What is the purpose of a pt pass?
allow the pt to leave for short time...usually 24-48 hours
Who is the approval authority for pt passes?
the pt's physician
Who is immediately notified when a pt does not return from a pass?
the physician
What is the purpose of convalescent leave?
To allow non-chargeable leave for recovery purposes
What is an interservice transfer and when is it used?
a transfer between services withouth physically moving the pt, used when the physician decides the pt needs special care
Who approves a medical facility transfer?
the chief of service
Who is responsible for the preparation of the pt's records for AE?
the AE clerk
How are paraplegic pt's transferred during AE?
ona stryker frame
What is the weight limit for pt's baggage during AE?
66 lbs
What are the three types of dispositions?
transfer, subsisting elsewhere, discharge
What info is included in the nurse's discharge note?
pt condition, final treatments, and discharge instructions
What AFI provides a list of forms to be assembled after the discharge of a pt?
AFI 41-210
What is the last office to be cleared by a pt when discharged?
Disposition clerk
What info must be on the pt's inpatient record?
at minimum the pt's name, ssn, admission registration #, and MTF name
What form is used to record intake and output?
DD form 792 intake and output record
What should be documented on the output intake form when starting an IV?
Fluid, date and time, amount started, rate, and meds in solution
How many pounds are in one kilo?
2.2
What type of pt may have daily abdominal girth measurements taken?
Cirrhosis of the liver, or possible internal bleeding
Who is responsible for ensuring documentation guidelines are in place and followed?
the chief nurse
what soes SOAPP stand for?
subjective info, objective info, assessment, plan, and prevention
What is OONDS?
Outcome oriented nursing documentation system
What form does a provider use to document orders on a pt admitted to the hospital?
AF for 3066 Doctors orders form
What are 2 uses for the AF form 3066?
transmit doctors orders to nurses and establish a drug profile on the pt
How does the nurse indicate that the physician's order have been carried out?
writing "noted" on orders sheet
What form or paperwork would you place on the front of a chart for a pt sheduled for surgery?
locally devised surgical checklist
What are the 2 categories normally found on a surgical checklist?
clinical records and pt care procedures
What is the OF 522 used for?
documenting pt consent for a procedure
What should you do with a pt's labs and x-rays the morning of a surgery?
Determine if and which labs and x-rays will be needed in the surgery packet
What actions should you take if your pt is wearing jewelry and he or she is going to surgery?
remove all jewelry and leave it with a family member or in a secure valuables vault
What specific actions would you take if the a pt was scheduled for hand or arm surgery?
assure that all jewelry and bands are removed from both hands wrists or arms
What do you do if there is a descrepancy between the pt's ID band and their surgical paperwork?
bring it to the attention of the nurse and fix it immediately
What are nursing activities designed to do?
Help pt achieve nursing goals and objectives
What are the 4 steps you use when you plan nusrsing care?
Make priorities, make goals, make objectives, select nursing activities
How are pt problems and diagnoses prioritized?
according to the most lif-threatening problem
What is a goal in terms of pt care?
an achievable statement of a change in pt behavior or condition
Who should you consult with when you set priorities and establish goals?
the pt
How do objectives relate to nursing goals?
objectives are daily steps towards achieving the goals
Briefly describe the steps you follow to implement a nursing activity?
Check physicians orders, organize, wash hands, get equipment, ID pt, explain and do procedure, observe, clean up, wash hands, report and record
What should you do if the nursing activity is unsuccessful?
figure out what when wrong and make a new plan
what are the 3 major goals in the preoperative period?
prepare pt mentally physically and spiritually
What nursing intervention can help to relieve most of the pt's concerns prior to surgery?
proper pt education and teaching
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