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NUC0520 NUC150 Laboratory Order Transcription > Activities and Roles > Flashcards

Activities and Roles Flashcards

1
Q

admission orders

A

Initial written directives by the doctor for the care and treatment of the patient.

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2
Q

What are 9 common components of an admission order?

A
  1. Admitting diagnosis
  2. Diet order
  3. Activity order
  4. Diagnostic tests/procedures order
  5. Nursing observation order
  6. Medication order
  7. Treatment order
  8. Patient code status order
  9. Miscellaneous order
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3
Q

What is an admitting diagnosis?

A

The diagnosis provided by the physician at the time of admission which describes the patient’s condition upon admission to the hospital.

Since the Admitting Diagnosis is formulated before all tests and examinations are complete, it may be stated in the form of a problem or symptom and it may differ from any of the final diagnoses recorded in the medical record.

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4
Q

What is a diet order?

A

A doctor’s order that states the type and quantity of food and liquids the patient may receive

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5
Q

What is an activity order?

A

A doctor’s order that defines the type and amount of activity a hospitalized patient may have

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6
Q

What is a diagnostic test/procedures order?

A

Tests ordered and performed for the evaluation of a prescribed treatment

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7
Q

What is a nursing observation order?

A

A doctor’s order that requests the nursing staff to observe and record certain patient signs and symptoms

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8
Q

What is a medication order?

A

a written order by a physician, dentist, nurse practitioner, or other designated health professional for a medication to be dispensed by a pharmacy for administration to a patient.

Usually medications are needed for the patient’s disease condition, for sleeping and for pain, nausea & vomiting

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9
Q

What is a treatment order?

A

A nursing treatment order is any act performed by a nurse that implements the nursing care plan or any specific objective of the clinical plan or pathway

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10
Q

What is a patient code status order?

A

Refers to the patient’s wishes regarding resuscitation

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11
Q

What is a miscellaneous order?

A

Miscellaneous requests not covered in the common components

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12
Q

activity order

A

Refers to the amount of walking, sitting and other motions that the patient may do in a given period during his or her hospital stay.

Activity changes are ordered to coincide with the patient’s stages of recovery.

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13
Q

CBR

A

complete bed rest

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14
Q

BR c̅ BRP

A

bedrest with bathroom privileges

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15
Q

dangle

A

The patient may sit and dangle his/her feet over the edge of the bed

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16
Q

Up in chair c̅ assist

A

The patient may sit in a chair with the assistance of a member of the nursing staff

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17
Q

BRP when A & O

A

the patient may use the bathroom as desired when alert and oriented

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18
Q

up in hall

A

the patient may walk in the hall

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19
Q

up as tol

A

the patient may be out of bed as much as he or she can physically tolerate

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20
Q

up ad lib

A

the patient has no restrictions on activity

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21
Q

OOB

A

the patient may be out of bed

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22
Q

Amb.

A

the patient must ambulate (walk) for prescribed periods of time

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23
Q

Walk c̅ assistance

A

physio or RN will assist patient to walk

24
Q

AAT

A

activity as tolerated

25
Q

What is the 4 roles of Nutrition Services?

A
  1. To meet the therapeutic needs and dietary preferences of the patient.
  2. Preparing and serving food for patients.
  3. To aid in development and monitoring of special therapeutic diets.
  4. Providing dietary information to patients
26
Q

What is a diet order?

A

A doctor’s order that states the type and quantity of food and liquids the patient may receive

27
Q

regular / general

A

for patients who have no dietary restrictions

28
Q

GI soft

A

for patients with nausea and distention, usually post surgical patient

29
Q

mechanical soft

A

for patients who have trouble chewing or swallowing

30
Q

pureed / minced

A

for patients with problems chewing and swallowing,

ex. no dentures

31
Q

no thin liquids / thick fluids only

A

to prevent choking

32
Q

diabetic diet

A

for patients who cannot produce enough insulin

33
Q

renal diet

A

for patients with renal disease

34
Q

neutropenic

A

to reduce the number of bacteria entering the stomach for patients on chemotherapy or those with immune deficiency diseases

35
Q

lactose controlled

A

for patients who experience stomach disturbances after drinking/eating products containing milk

36
Q

nothing by mouth (NPO)

A

for patients pre & post surgery, scheduled for procedures, tests or as indicated

37
Q

clear fluids

A

for patients whose digestive system should not or cannot digest whole foods.

Ex. Pre and post surgery

38
Q

full fluids

A

for patients who cannot eat solid foods

39
Q

cardiac diet

A

low sodium, no sugar, low cholesterol

40
Q

controlled sodium

A

for patients with heart disease, high blood pressure, kidney disease, or may be using certain drugs

ex. 2 gm NA or NAS

41
Q

controlled calorie

A

Limited caloric intake

ex. 1,400 calorie reduced diet

42
Q

tube feed

A

for patients who must be fed by GI or NG tube

ex. Isosource 50-100 cc q2h

43
Q

dysphagia / thickened

A

thickened fluids for a patient with swallowing difficulties

44
Q

DAT

A

allows the nursing staff to advance patients diet as tolerated without phoning the Doctor for a new order

may start as CF – General tray

Will not always notate “DAT” on PO

45
Q

What are 5 miscellaneous diet orders?

A
  1. Hold tray / early tray / late tray
  2. Fluid restrictions
  3. Push or force fluids
  4. Natural laxatives
  5. Calorie count
46
Q

hold tray / early tray / late tray

A

for patients going to or returning from OR, tests, or treatments

47
Q

fluid restrictions

A

patients retaining fluids in tissues (edema)

48
Q

push or force fluids

A

patients are dehydrated and require additional juices, tea, etc.

49
Q

natural laxatives

A

bran, fruitlax, etc. ordered by doctor

50
Q

calorie count

A

a 24-hour calorie count record, RN records each item patient has eaten on the calorie count sheet

51
Q

Who can receive a snack between meals?

A

Patients on a special diet can receive a snack (not a meal) between meals.

Delivered to the unit and given to the patient by the RN

52
Q

Who can receive a bedtime snack?

A

Diabetic patients

53
Q

Where can you get a bottle of water for a patient?

A

Stocked in the ward. Supplied by Food and Nutrition Services

54
Q

What food supplies can the NUC order to keep in the ward?

A
  • juice
  • bread
  • butter
  • jell-o
  • ice cream
  • milk
  • sugar
  • cheese
  • crackers
  • ginger ale
  • popsicles
  • peanut butter
  • jam

etc

55
Q

For training purposes, what are the routine blood draw times?

A
  • 0700
  • 0900
  • 1100
  • 1300
  • 1500
  • 1700
  • 1900
56
Q

STAT blood orders follow the routine blood draw times, true or false?

A

false

NUC0520 NUC150 Laboratory Order Transcription (12 decks)

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