Activities and Roles Flashcards
admission orders
Initial written directives by the doctor for the care and treatment of the patient.
What are 9 common components of an admission order?
- Admitting diagnosis
- Diet order
- Activity order
- Diagnostic tests/procedures order
- Nursing observation order
- Medication order
- Treatment order
- Patient code status order
- Miscellaneous order
What is an admitting diagnosis?
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.
What is a diet order?
A doctor’s order that states the type and quantity of food and liquids the patient may receive
What is an activity order?
A doctor’s order that defines the type and amount of activity a hospitalized patient may have
What is a diagnostic test/procedures order?
Tests ordered and performed for the evaluation of a prescribed treatment
What is a nursing observation order?
A doctor’s order that requests the nursing staff to observe and record certain patient signs and symptoms
What is a medication order?
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
What is a treatment order?
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
What is a patient code status order?
Refers to the patient’s wishes regarding resuscitation
What is a miscellaneous order?
Miscellaneous requests not covered in the common components
activity order
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.
CBR
complete bed rest
BR c̅ BRP
bedrest with bathroom privileges
dangle
The patient may sit and dangle his/her feet over the edge of the bed
Up in chair c̅ assist
The patient may sit in a chair with the assistance of a member of the nursing staff
BRP when A & O
the patient may use the bathroom as desired when alert and oriented
up in hall
the patient may walk in the hall
up as tol
the patient may be out of bed as much as he or she can physically tolerate
up ad lib
the patient has no restrictions on activity
OOB
the patient may be out of bed
Amb.
the patient must ambulate (walk) for prescribed periods of time
Walk c̅ assistance
physio or RN will assist patient to walk
AAT
activity as tolerated
What is the 4 roles of Nutrition Services?
- To meet the therapeutic needs and dietary preferences of the patient.
- Preparing and serving food for patients.
- To aid in development and monitoring of special therapeutic diets.
- Providing dietary information to patients
What is a diet order?
A doctor’s order that states the type and quantity of food and liquids the patient may receive
regular / general
for patients who have no dietary restrictions
GI soft
for patients with nausea and distention, usually post surgical patient
mechanical soft
for patients who have trouble chewing or swallowing
pureed / minced
for patients with problems chewing and swallowing,
ex. no dentures
no thin liquids / thick fluids only
to prevent choking
diabetic diet
for patients who cannot produce enough insulin
renal diet
for patients with renal disease
neutropenic
to reduce the number of bacteria entering the stomach for patients on chemotherapy or those with immune deficiency diseases
lactose controlled
for patients who experience stomach disturbances after drinking/eating products containing milk
nothing by mouth (NPO)
for patients pre & post surgery, scheduled for procedures, tests or as indicated
clear fluids
for patients whose digestive system should not or cannot digest whole foods.
Ex. Pre and post surgery
full fluids
for patients who cannot eat solid foods
cardiac diet
low sodium, no sugar, low cholesterol
controlled sodium
for patients with heart disease, high blood pressure, kidney disease, or may be using certain drugs
ex. 2 gm NA or NAS
controlled calorie
Limited caloric intake
ex. 1,400 calorie reduced diet
tube feed
for patients who must be fed by GI or NG tube
ex. Isosource 50-100 cc q2h
dysphagia / thickened
thickened fluids for a patient with swallowing difficulties
DAT
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
What are 5 miscellaneous diet orders?
- Hold tray / early tray / late tray
- Fluid restrictions
- Push or force fluids
- Natural laxatives
- Calorie count
hold tray / early tray / late tray
for patients going to or returning from OR, tests, or treatments
fluid restrictions
patients retaining fluids in tissues (edema)
push or force fluids
patients are dehydrated and require additional juices, tea, etc.
natural laxatives
bran, fruitlax, etc. ordered by doctor
calorie count
a 24-hour calorie count record, RN records each item patient has eaten on the calorie count sheet
Who can receive a snack between meals?
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
Who can receive a bedtime snack?
Diabetic patients
Where can you get a bottle of water for a patient?
Stocked in the ward. Supplied by Food and Nutrition Services
What food supplies can the NUC order to keep in the ward?
- juice
- bread
- butter
- jell-o
- ice cream
- milk
- sugar
- cheese
- crackers
- ginger ale
- popsicles
- peanut butter
- jam
etc
For training purposes, what are the routine blood draw times?
- 0700
- 0900
- 1100
- 1300
- 1500
- 1700
- 1900
STAT blood orders follow the routine blood draw times, true or false?
false
