Final Review Flashcards
PCA
patient controlled analgesia
PCA allows the patient to self-administer small doses of narcotics intravenously.
A special IV infusion pump is used and an order is written of a specific amount of medication.
How is PCA transcribed on the Kardex in most hospitals?
“PCA orders” in the intravenous/treatment section
example: PCA Morphine
How is PCA transcribed on the MAR in most hospitals?
“PCA orders” on the routine MAR
example on routine MAR:
Morphine PCA 1 mg/mL - 30 mL vial inj as per PCA standing order sheet
epidural / spinal analgesic
A special needle is placed in the spine that surrounds the nerves and blocks out pain.
It decreases sensation in the lower part of the body while the patient remains conscious.
Post-Op Clinical Pathway / Care Paths
Pre-printed orders that are used as a method of outlining a patient’s path and included doctor’s orders for a specific diagnosis
4 functions of Physical Therapy dept
- Identify and manage movement dysfunction by improving muscle strength and physical abilities
- Restore, maintain, and promote optimal wellness and fitness
- Make recommendations and offer training in the use of equipment that assists in replacing lost function or promotes achievement of independent movement
- Provides guidance to family members in safe and effective methods of caring for the patient
Functions of Occupational Therapy dept
- Gives people the “Skills for the Job of Living”
- Customized treatment programs aimed at improving abilities to carry out the activities of daily living
- Assessment and treatment necessary to enhance development and performance and/or to regain function
- Recommendations and training in the use of equipment that assists in replacing lost function
- Recommendations regarding adaptation of the home environment
- Guidance to family members and caregivers
Functions of Speech Therapy dept
- Therapy for patients with speech/language impairment as a result of stroke, dementia, and various neurological disorders
- Cognitive-linguistic deficits following head injury
- Post-operative counseling for layngectomized patients
- Voice disorders resulting from disease or misuse of the voice
- Speech disorders
- Swallowing disorders
Common signs of swallowing difficulties
- Coughing during eating or drinking
- A wet/gurgly voice during or after eating
- A tendency to hold food or drink in the mouth for prolonged periods of time
- Difficulty eating hard, chewy or crumbly foods
- Shortness of breath induced by eating or drinking
- A long time taken to eat or drink
- Loss of weight because of prolonged eating time, poor appetite or avoidance of certain foods
- Recurrent chest infections or pneumonia requiring hospitalization
- Drooling of saliva or inability to swallow ones own secretions
- Refusal to eat
What is another name for swallowing difficulties?
dysphagia
What info must the NUC have to book patient transport?
- patient name
- personal health number
- date of birth
- gender
- pickup facility, unit telephone number
- drop off facility, unit telephone number
- date and time of appointment/return time
- reason for transfer
- what procedure is being done
- any monitoring required (O2, IV, telemetry)
- contact precautions
- weight of patient
- special equipment
- escort info
Steps to process home O2
- Record the order on the Kardex under “discharge plans”
- Addressograph/label a “home oxygen program application” and clip to the chart for the dr to complete and sign
- Fax once completed to Home O2 Program and Medi Gas/Vital Air
- Fax stamp with date, time, initials, status. File in the history section of the patient’s chart
- Symbolize on PO: I/C, K, RMO
- HC liaison nurse will take a photocopy of the application
- File the completed patient’s copy in the history section
Operating Room chart forms in the correct order
- Surgical Consent Form
- Pre-op Checklist / OR Check Off List
- Anesthetic Record
- Surgical Count Sheet
- Perioperative Record
- Operation Report
- PACU Record
Types of pre-op orders and examples
Diet - NPO > MN
Vital Signs - RVS q2hr pre-op
Bloodwork - CBC, INR, PTT, U/A
Diagnostic Tests - ECG, CXR
IV Orders - IV D5W @ 120 mL/hr start 1 hr pre-op
Medications - Ativan, Maxeran, ranitidine, Ancef (antibiotics)
OR slate
Schedule of surgeries to be done the following day with list of patients on the ward
Pre-op checklist for day prior to surgery
- Ensure all pre-op orders have been processed
- Record surgery, date and time on the Kardex (originally in pencil)
- Write OR date and time on any reqs prn
- Ensure Surgical Chart Pack is addressographed and clipped to the chart for the RN to complete
- Ensure Consent Form is completed and clipped to chart
Pre-op checklist for morning of sugery
- Ensure all diagnostic reports are filed in the patient’s chart and consent form is signed
- Attach addressograph (or 10-12 labels) to the chart
- Collect any old or thinned charts and current chart. Send to OR with the patient
- Ensure that all orders have been processed
- Attach the current MAR to the patient’s chart
- Draw a line after last physician’s order and write “TO OR”
- Draw diagonal lines through remainder of blank form
- Ensure there are several blank physician’s orders in chart
Post-op checklist
- Inform RN of patient’s arrival from PAR
- Remove addressograph (or extra labels) and return to addressograph holder
- Place old thinned charts in the appropriate place
- Place all OR records behind the proper dividers in the correct order in the chart
- Record date and type of surgery performed on the kardex under “operations” in ink (info found on the surgical report)
- Scan orders for medications and send copy to Pharmacy is not already done in PAR
- Transcribe the post-op orders, informing RN of any STAT orders
- All pre-op orders are automatically discontinued and a new MAR is started (sometimes in PAR)
Reasons that a patient may require Home Care upon discharge
- Patients who are unable to provide appropriate self-care
- When there is no available caregiver who is willing and able to learn to provide the care
- If the care needs of the patient require the expertise of an RN
Home Care Nursing checklist
- Transcribe the order on the Kardex under referrals to “Home Care” or “Discharge Plans”
- Addressograph and fill out a Home Care Referral form
- Clip to front of chart for the dr to complete and sign
- Once completed, fax to the appropriate Home Care office along with copy of patient’s admission record and fax cover sheet
- Fax stamp the req
- Symbolize on PO: K, RMO
- File a copy of the req in the Multidisciplinary section of the chart
Functions of the Social Word dept
- Provides much needed information concerning resources available to patients and their families
- Assess family/social situations
- Assess for Long Term Care
- Locate and arrange resources
- Substance abuse
- Psychological counselling
- Discharge planning
Social Worker checklist
- The order is to communicate to the Social Work dept by computer or requisition. If by req, fax to the Social Work dept
- Record the order under the referral section for Social Work or the Discharge Planning section of the Kardex
- Complete a Social Work referral req with all pertinent info required. Fax stamp the completed req
- Symbolize on PO; I/C, K, RMo
- File original req in “Multidisciplinary” or “social work” section of patient’s chart. After SW has assessed the patient, their written report will print out on the unit. File in the patient’s chart
Functions of Respiratory Services
- Performs diagnostic tests to determine lung function (spirometry) and O2 saturation (oximetry)
- Assists with the maintenance of patients on ventilators
- Provide portable oxygen for patients who require temporary O2 while being transported to other departments
- Attend cardiac arrests (code blue)
- Draw ABG’s to assess patient’s adequacy of oxygenation
- Home Oxygen Program assessment - assess needs of oxygen at home
- Set up and monitor equipment that provides positive pressure in the airways
4 ways O2 can be administered
- nasal cannula (nasal prongs)
- simple oxygen mask
- Venturi oxygen mask
- nebulizer
aerosol therapy
Administration of a bronchodilator in the form of a mist or puffer
oximetry
oxygen saturation
Performed to determine the amount of O2 in the blood
spirometry
pulmonary function tests
Measurement of the air capacity of the lungs
Spirometry checklist
- Kardex the order under “diagnostic tests”
- Complete the Respiratory Services req
- Clip to chart for dr to complete and sign
- Send completed req to Respiratory services and they will advise appointment date and time
- Symbolize on the PO: K, RMO
BCCA checklist
- Record on Kardex under referral/treatment section
- Addressograph/label the BCCA referral form
- Complete fax cover sheet indicating a referral with this info:
- patient name
- date of birth
- advise requested info is attached
- request confirmation of appointment date and time
- Fax all pertinent info to the Cancer Agency as required:
- all pathology and/or cytology reports
- operative reports
- diagnostic imaging reports
- laboratory reports
- all consultation reports
- any specialized test such as PFT’s, hormone receptor’s for Breast Cancer patients
- all or any treatment records such as chemotherapy or radiotherapy the patient may have already had
- all pendent procedures, test, and consult info
- When confirmation is received for the appointment date and time, transcribe on the Kardex under the referral/treatment section with order and appointment info
- Symbolize on PO - K, RMO
- Fax stamp the req - faxed @ time, initials, status
- File in history section of chart
- Arrange for patient transport
On the fax cover sheet for BCCA referral, what info needs to be in the comments section?
- patient name, date of birth, PHN
- patient referral form
- consults
- diagnostic results
- operative results prn
- specialized tests
- Please advise appointment date and time
Outpatient Clinic referral checklist
- Record the order under “Discharge Plan” section of the Kardex
- Complete the “Outpatient Clinic req” with all pertinent information
- Clip to chart for dr to complete and sign
- Fax requisition or call the outpatient clinic requesting booking of appointment date and time
- Record appointment info on Kardex
- Give patient/family appointment card with details
- Fax stamp the req with time, status, initials
Symbolize on PO: K, RMO, Appt
Outpatient IV Therapy checklist
- Record the discharge and follow up appointment in the Discharge Plan section of the Kardex
- Complete a follow up appointment card with doctor name, office #, and follow up date requested. Hole punch and place in front of dr’s orders. RN will give to patient at time of discharge
- Symbolize on PO: K, RMO
Reasons for surgical procedure
- Further explore the condition for the purpose of diagnosis
- Take a biopsy of a suspicious lump
- Remove diseased tissues or organs
- Remove an obstruction
- Reposition structure to their normal position
- Redirect channels
- Transplant tissue or whole organs
- Implant mechanical or electronic devices
- Improve physical appearance
Physician Consult checklist
- Kardex the order under consultations/referral
- Addressograph and complete a Consultation Requisition with all pertinent information:
- date
- patient’s name
- room and bed number
- referring dr
- patient diagnosis
- reason for referral
- Page or phone consultant’s office with requested information:
- patient’s name
- room and bed number (hospital if outside consultant)
- referring dr
- patient diagnosis
- urgency of consultation
- patient’s PHN, if outside consultant
- On the requisition record paged @ time, pager #, initials, status
- Symbolize on PO: K, RMO, paged @ time
- Clip requisition to chart for consultant to complete
- File in History section of chart
3 areas of the Rehabilitation Medicine dept
- Physical Therapy
- Occupational Therapy
- Speech Language Pathology
Why do surgical patients require further IV Abx’s?
To ensure there is no risk of post-op infection
Why do patients require a referral to outpatient clinics?
Many patients require follow up and treatment after being discharged from the hospital.
The patients are both surgical and medical in nature and may require assistance of specialized health care providers
Rather than keep patients who require further IV Abx treatment in the hospital, what can be arranged?
For the patient to come into the hospital/IV Clinic for the daily administration of their IV antibiotics
Where is the order for Outpatient IV therapy recorded on the Kardex?
Under Discharge Plan section
What is done with the Outpatient IV therapy sheet before the dr has signed it and the NUC has completed the routines?
Addressograph/label and clip to front of chart for the dr to sign
When a PO for Outpatient IV therapy is written, what is sent to the IV clinic with the order/referral?
The patient’s administration record
How do you symbolize the PO
K, RMO
How does the NUC symbolize the PO after processing a referral to the Outpatient Clinic?
K, RMO, Appt
Specialized health care providers / clinics
- Walk-in psychiatry
- Acute Pain Clinic
- Wound healing clinic
- Infectious disease
- TIA and stroke prevention
- Respiratory Rapid Access
- Chest pain clinic
- Cast clinic
- Diabetes Clinic
- Nutritional counselling
Where does the NUC transcribe the order for an Outpatient referral?
Under the Discharge Plan section on the Kardex
Once the appointment info is received from the Outpatient Clinic, what does the NUC do?
Record the appt info on the Kardex, and give the patient/family the appt card with details
