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)
