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VET 2050 Fa24 > Animal Nursing and Care > Flashcards

Animal Nursing and Care Flashcards

1
Q

In what species can a diminished sense of smell lead to anorexia more than others?

A

Felines
#11, McCurnin’s (electronic version) 10th ed. Pg 1876

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1
Q

What does the term pleural effusion refer to?

A

Pleural effusion is the build-up of excessive fluid in the thoracic cavity. This can be caused by infection, lymphatic obstruction, coagulopathies, and trauma.
#11, McCurnin’s (electronic version) 10th ed. Pg 1878

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2
Q

What are examples of airway
humidification?

A

Vaporizers, nebulization, steam therapy, saline nasal drops, and systematic hydration
#11, McCurnin’s (electronic version) 10th ed. Pg 1881

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3
Q

What is regurgitation?

A

A passive expulsion of material from the pharynx, mouth, or esophagus. (Nausea and abdominal contractions are unusual to observe).
#11, McCurnin’s (electronic version) 10th ed. Pg 1892

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4
Q

What term is used to describe patients who are vomiting flesh or digested blood?

A

Hematemesis
#11, McCurnin’s (electronic version) 10th ed. Pg

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5
Q

What is the order of patients physiologic needs?

A
  1. oxygenation
  2. critical safety/ severe pain
  3. hydration
  4. elimination
  5. nutrition
  6. noncritical safety
  7. chronic pain, mild-moderate acute pain
  8. actility
  9. utility
    McCurnin’s 10th ed. Pg. 92
    #5
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6
Q

What are the 2 purposes that logs serve?

A

provide additional documentation for legal support and provide data for quick analysis and retrospective studies.
McCurnin’s 10th ed. Pg. 95
#5

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7
Q

What is the master problem list?

A

Includes the major medical disorders experienced by a patient during its lifetime
McCurnin’s 10th ed. Pg. 85
#5

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8
Q

What is the working problem list?

A

Often used in a vet practice to assist the team in working through current problems
McCurnin’s 10th ed. Pg. 85
#5

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9
Q

How many years should a vet practice store records before getting rid of them?

A

8 years
McCurnin’s 10th ed. Pg. 100
#5

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10
Q

What is informed consent?

A

It is the owner’s agreement to allow something to happen such as diagnostics, treatments, or surgical intervention. This should only occur after being educated of the issue and prognosis of the pet using language that can be easily understood

JY #19, McCurnin’s 10th ed. Pg. 75

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11
Q

What are a few things a clinic can do to minimize risk of loss with digital records?

A
  1. Surge Protectors
  2. Backup generators
  3. Backup servers for data

JY #19, McCurnin’s 10th ed. Pg. 95

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12
Q

If a hospital is using paper records, how often should the medical records be reviewed/purged?

A

At least once a year

JY #19, McCurnin’s 10th ed. Pg. 101

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13
Q

What information should be given to an owner after their pet is discharged from the hospital?

A
  1. A clear and concise summary of the pet’s illness, prognosis, and treatment
  2. Instructions for continued care at home including instructions for medications
  3. A signed form acknowledging that owner understands all the information that was presented on discharge

JY #19, McCurnin’s 10th ed. Pg. 91

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14
Q

What is the technician’s role for the Plan portion of SOAP notes?

A

The technician should discuss client education, medication administration, follow-up appointments, and any other recommendations the doctor has for continued patient care

JY #19, McCurnin’s 10th ed. Pg. 87

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15
Q

Companies that specialize in housing medical databases can also do what?

A

Act as third-party agents to verify the originality of record, or any tampering.
#9 McCurnin’s 10th Edition pg. 94

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16
Q

With an EMR how long do you have to make changes?

A

24 to 48hrs
#9 McCurnin’s 10th Edition pg.94

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17
Q

What are advantages of an electronic MAOR?

A

Legibility, retrievability from any computer, dual functionality, and visibility of multiple patients.
#9 McCurnin’s 10th Edition pg.88

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18
Q

What are 3 secondary purposes of the medical record?

A

Billing verification, serves as a legal document, and supports inventory maintenance
#9 McCurnin’s 10th Edition pg.74

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19
Q

Medical records are property of the client or veterinary practice?

A

Veterinary practice
#9 McCurnin’s 10th Edition pg. 78

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20
Q

When does the assessment of the patient begin?

A

From a distance, before the cage/stall door is opened
#10 JM
McCurnin 10th ed pg 90

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21
Q

Which type of client communications should be included in a patients medical record?

A

Phone calls, text messages, emails, verbal communication
#10 JM
McCurnin 10th ed pg 92

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22
Q

Should a patient’s discontinued medication be deleted from their medical record?

A

10 JM

No, it should be recorded as being discontinued, not erased.

McCurnin 10th ed pg 91

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23
Q

If records kept are ineligible, they can prove ____ in a court of law.

A

10 JM

Indefensible

McCurnin 10th ed pg 97

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24
Q

How long should inactive records be kept before being shredded?

A

10 JM

8 years

McCurnin 10th ed pg 100

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25
Q

What is a Notation?

A

Any information entered into progress notes but independent of the SOAP notes
8 PL McCurnin 10th Edition pg.88

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26
Q

What is a Problem-Oriented Veterinary Medical Record (POVMR)

A

An organized approach to vet care because the information is grouped by problem allowing each problem to be addressed separately
8 PL McCurnin 10th Edition pg. 80

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27
Q

What is the purpose of the Medication administration/order record

A

ensures hospitalized patients are given treatment, diagnostic tests and diets as requested by the DVM
8 PL McCurnin 10th Edition pg. 88

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28
Q

What is the purpose of cage card

A

To provide proper identification of each animal as well as the reasoning of them being ther.
8 PL McCurnin 10th Edition pg. 91

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29
Q

What would the response of a lost record be for the veterinary team?

A

First inform the owner about the misplacement of the medical record and a new record should be started with information from the client, tech, vet, and all laboratory/medication data possible.
8 PL McCurnin 10th Edition pg. 100-101

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30
Q

What are some possible Technician Evaluations that fall under Oxygenation?

A
  • Altered Gas Diffusion
  • Risk of Aspiration
  • Obstructed Airway

McCurnin 10th Ed. Pg. 92 #17 AG

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31
Q

What are the steps of a the veterinary nursing process?

A
  1. Assessment
  2. Planning
  3. Implementation
  4. Evaluation

McCurnin 10th Ed. Pg. 593 #17 AG

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32
Q

What are some clinical signs that occur with Pneumonia?

A

Cough, Hypoxia, Lung ‘Crackles’, Fever, Anorexia

McCurnin 10th Ed. Pg. 592 #17 AG

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33
Q

What information should be obtained during a basic history?

A
  1. Origin
  2. Preventative Medicine
  3. Behavior
  4. Environment
  5. Nutritional History
  6. Reproduction
  7. Previous Conditions
  8. Medications, Treatments, and Responses
  9. Prior Referral History

McCurnin 10th Ed. Pg. 82 #17 AG

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34
Q

What are the basic components of a Problem-Oriented Medical Record?

A
  1. Database - Client info and History
  2. Master Problem List and Working Problem Lists
  3. Initial Plan and Progress Notes
  4. Case Summary and Discharge Instructions
35
Q

Whaat should medical record entries include?

A

1 IB

entered chroniclogically by date and time, accurate and concise, torough and objective, use only standard abbreviations from AAHA

McCurrin’s 10th edition pg 73

36
Q

If it was not written down or _____________ into the patient’s medical record it ___________________.

A

1 IB

electronically entered
did not happen

McCurrin’s 10th edition pg 76

37
Q

How do you fix a mistake in the medical record?

A

1 IB

draw a single line through and and write error in margin with correct info and initialed with date

McCurrin’s 10th edition pg 77

38
Q

What contact information should be included with clients?

A

1 IB

mailing address, cell phone #, office #, e-mail address

McCurrin’s 10th edition pg 80

39
Q

What does a comprehensive history include?

A

1 IB

previous and recent history information

McCurrin’s 10th edition pg 81

40
Q

What criteria must me met to maintain a VCPR (veterinarian-client-patient-relationship)?

A

1) veterinarian assumes responsibility of patient’s health/medical needs and client agrees to follow instructions
2) veterinarian has recently seen patient and has knowledge of medical conditions
3) veterinarian is available for follow-up appointments
4) veterinarian provides oversight of treatment, compliance, and outcome
5) patient medical records are maintained

SS 18
McCurnin’s 10th Edition
pg. 75

41
Q

What are the “5 Freedoms of Animal Welfare?”

A

1) Freedom from hunger and thirst
2) Freedom from discomfort
3) Freedom from pain, injury, and disease
4) Freedom to express normal behavior
5) Freedom from fear and distress

SS 18
McCurnin’s 10th Edition
pg. 581

42
Q

What are the general steps to development of disease?

A

Etiology > pathogenesis > lesions > clinical signs

SS 18
McCurnin’s 10th Edition
pg. 583

43
Q

What clinical signs may be seen in a patient with pleural effusion?

A

Respiratory distress with increased inspiratory effort

SS 18
McCurnin’s 10th Edition
pg. 589

44
Q

Define systemic hypertension

A

Increase in systemic BP with risk of organ damage seen in calm patients with BP 150 mmHg or greater

SS 18
McCurnin’s 10th Edition
pg. 593

45
Q

What do each letter in SOAP stand for?

A

S: Subjective
O: Objective
A: Assessment
P: Plan
#6
McCurrin’s 10th edition pg 86-87

46
Q

What are the primary 5 purposes of the medical record?

A

1: Identification of the correct patient and client
2: Documentation and support of diagnostic procedures and diagnoses, prognoses, and treatment plans
3: Supports continuity of care
4: Supports communication between health care team members and the client
5: Personalizes the VCPR
#6
McCurrin’s 10th edition pg 74

47
Q

What is the most common deficit cited by state veterinary examination boards in investigations of complaints?

A

Incomplete medical records
#6
McCurrin’s 10th edition pg 75

48
Q

What is a source-oriented veterinary medical record? SOVMR

A

A system that organizes patient information by subject matter. Such as lab reports being separate from progress notes. Clinical observations and notes are written in chronological order.
#6
McCurrin’s 10th edition pg 80

49
Q

Why are electronic medical records preferential in an ambulatory setting?

A

This is because their vehicles are often filled with necessities, and do not have room in them for large cumbersome medical records.
#6
McCurrin’s 10th edition pg 101-102

50
Q

Why is it so important that everything entered into a medical record is ethical and professionally worded?

A

Owners can request a copy of records any time they want.

3 LD
McCurnin’s 10th ed
pg 74

51
Q

What are the two scenarios when a medical record or information on a medical record can be given out without client permission?

A

If a reportable diseas has been diagnosed or if a medical record is subpoenaed by a court of law.

3 LD
McCurnin’s 10th ed
pg 78

52
Q

True or False:

The integrity of an entire medical record can be questioned if one piece is inaccurate or tampered with?

A

True

3 LD
McCurnin’s 10th ed
pg 76

53
Q

Are any abbreviations allowed to be used while writing medical records?

A

Only very common abbreviations should be used in medical records ex: “WNL”, “NSF”, “BAR”

3 LD
McCurnin’s 10th ed
Pg 82

54
Q

What are some technician evaluations that relate to nutrition?

A

Altered oral health, abnormal eating behavior, ineffective nursing, overweight, self-care deficit, underweight, vomiting/diarrhea

3 LD
McCurnin’s 10th ed
pg 92

55
Q

What should always be included in MAORs?

A

7 MJ

Patient’s full name, patient ID #, signalment, and any know allergies

McCurnin’s 10th ed pg 89

56
Q

What are some technician evaluations for hydration status?

A

7 MJ

  • Hypervolemia
  • Hypovolemia

McCurnin’s 10th ed pg 92

57
Q

What are the functions of a medical record?

A

7 MJ

  1. Providing continuity of care of the patient
  2. Accurately identifying the patient and client

McCurnin’s 10th ed pg 72

58
Q

What resource can one refer to for the use of standard abbreviations?

A

7 MJ

AAHA standard abbreviations publication

McCurnin’s 10th ed pg 73

59
Q

What are the two categories of the medical record and what is their function?

A

7 MJ

  1. Primary purposes (Medical care based)
  2. Secondary purposes (Business and legal based)

McCurnin’s 10th ed pg 74

60
Q

What should we be worried about if the power goes out?

A

Monitors and monitoring devices, electrical instruments, records, and patients
KB2, McCurnin’s 10th ed pg 95

61
Q

Can two animals share a record?

A

No, each animal must have its own record by AAHA standards
KB2, McCurnin’s 10th ed pg 100

62
Q

What is VCPR?

A

VCPR stands for veterinarian client patient relationship
KB2, McCurnin’s 10th ed pg 75

63
Q

What is informed concent?

A

it is defined as a persons agreement to allow something to happen such as medical, diagnostic, or surgical procedure, based on full disclosure of facts necessary to make an intelligent decision
KB2, McCurnin’s 10th ed pg 75

64
Q

What is the purpose of drug logs?

A

To provide additional documentation for legal support, and to provide quick analysis and retrospective studies
KB2, McCurnin’s 10th ed pg 95

65
Q

What is “signalment”?

A

Identifying information of the patient: Name/number, species and breed, gender and reproductive status. Age, color and any special markers.

McCurnin 10th ed pg80
#15

66
Q

What are the different formats for veterinary records?

A

Source-oriented veterinary medical record, Problem-oriented veterinary medical record, and combination

McCurnin 10th ed pg 79
#15

67
Q

Does HIPAA apply to animal records?

A

HIPAA does NOT apply to animal records, however each state has it’s own privacy laws listed on the AVMA website

McCurnin 10th ed pg78
#15

68
Q

In the absence of internet connection what can be used as an alternative to a paper medical record for ambulatory practices?

A

A “ checked out” copy of the practice database.
P. 101 Ch.3 McCurnin’s Clinical Textbook for Veterinary Technicians and Nurses 10th ed. GMR #13

69
Q

Name 3 examples of Veterinary Practice Management software.

A

AVImark, Cornerstone Practice Management, IntraVet
p. 73 Ch.3 McCurnin’s Clinical Textbook for Veterinary Technicians and Nurses 10th ed. GMR #13

70
Q

What should be included in the assessment part of the SOAP?

A

Analysis of all subjective and objective data that have been gathered so far, technician evaluations that reflect patients physical, psychological, social and environmental conditions, based on the data gathered.
p. 87 Ch.3 McCurnin’s Clinical Textbook for Veterinary Technicians and Nurses 10th ed. GMR #13

71
Q

What should be included in the plan part of the SOAP?

A

Interventions for each of the evaluations listed in the assessment portion of the SOAP which constitutes the technician care plan for the patient.
P. 87 Ch.3 McCurnin’s Clinical Textbook for Veterinary Technicians and Nurses 10th ed. GMR #13

72
Q

What goes in the subjective and objective part of a SOAP?

A

Subjective- non-measurable information
Objective- measurable information
P. 86-87 Ch.3 McCurnin’s Clinical Textbook for Veterinary Technicians and Nurses 10th ed. GMR #13

73
Q

How should we prioritize our tech evaluations?

A
  1. Oxygenation
  2. Critical safety/ severe pain
    3.Hydration
  3. Elimination
  4. Nutrition
  5. Noncritical safety
  6. Chronic pain/ mild-to-moderate acute pain
  7. Activity
  8. Utility

McCurnin 10th ed pg92
#15

74
Q

Approximately how long should files be kept?

A

8 years before they can be tossed, but may vary by state.

McCurnin 10th ed pg 100
#15

75
Q

True or False. Clients have the right to see or have a copy of their pets medical record upon request?

A

True. Pg 74 Ch.3 McCurnin’s 10th ed #12

76
Q

In hand written entires what should be included for proper identification in a court of law?

A

Signed or initialed by the author, and author’s credentials, with date and time.
Pg 77 Ch.3 McCurnin’s 10th ed #12

77
Q

What can recent history information include?

A
  1. Presenting complaint and circumstances
  2. Date when last normal
  3. Location and characteristic of problem
  4. Current medications
  5. Treatment efforts
  6. Comments and concerns of the owner
  7. Current diet
  8. Recent changes in environment, and household
  9. FAS score
  10. Information from previous or referring veterinarian.
    Pg 82 Ch.3 McCurnin’s 10th ed #12
78
Q

What is a medication administration/order record (MAOR)?

A

Is known as a ward treatment sheet, it is used to ensure that hospitalized patients are given treatments, diagnostic tests, and diet as requested by the attending veterinarian.
Pg 88 Ch.13 McCurnin’s 10th ed #12

79
Q

What are the different types of diagnostic tests that can be performed on animals?

A

CBC, Chem profile, urine and fecal analysis, radiology, ultrasonography, electrocardiography, electroencephalography, endoscopy, scintigraphy, computed tomography, and magnetic resonance imaging.
Pg 82 Ch.3 McCurnin’s 10th ed #12

80
Q

Is pain level subjective or objective?

A

Objective, so long as it is uniformly employed within a practice.
14 BR
McCurnin’s 10th ed. pg 87

81
Q

What should be done when there is any indication that a client might cause a problem?

A

Obtain a consent form.
14 BR
McCurnin’s 10th ed. pg 76

82
Q

What is a Laboratory Diagnostic Summary and Flow Sheet?

A

A single form designed to display all diagnostic testing results in one palce.
14 BR
McCurnin’s 10th ed. pg 85

83
Q

What is an EMR?

A

An Electronic Medical Record.
14 BR
McCurnin’s 10th ed. pg 73

84
Q

What are advantages of a numeric filing system?

A

Numbers are easier to read and interpret, leading to fewer filing errors
Unique file identifiers prevent duplicate file names.
Enhanced protection of client information since names aren’t externally visible.
14 BR
McCurnin’s 10th ed. pg 100

85
Q
A

VET 2050 Fa24 (11 decks)

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