mi 116 unit 2 Flashcards
what is needed and what must be identified
patient bracelet (name and DOB)
how many identifiers are needed and why
two; to make sure the patient is getting the right treatment
red
allergy
yellow
fall risk
purple
DNR
green
latex allergy
orange
blood bank
hot pink
arm restriction
6 types of wristband errors
absent wrist band, wrong wrist band, more than one wrist band, partially missing info, partial erroneous info on wrist band, illegible identification
standard precautions
protection for the patient, yourself, and anyone else you directly or indirectly contact
history taking
be specific and obtain clinical information to contribute to diagnosis process
ways to interview
respect by always introducing yourself and using MR. &Ms.
genuineness
empathy by sharing concern
objective
signs that can be seen, heard, felt, smelled or read on a chart
subjective
data perceived only by patient=emotions, level of pain
questioning skills
open ended questions, facilitation, silence, probing questions, repetition and summarization
chief complaint
single most important issue of the patients clinical history, allows the radiologist to focus on a specific area, do not need a complete medical history
sacred seven
localization, chronology, quality, severity, onset, aggravating or alleviating factors, associated manifestations
localizations
palpation (defines the exact, precise area of concern of the chief complaint
chronology
time (duration since onset), frequency, course
quality
character of the symptom
severity
intensity, quantity, extent
onset
what were you doing when it happened ?
what else to look for while taking history and images
balance, level of consciousness, range of motion, pain and vital signs
end of history taking
pre-exposure instructions, length of procedure, immobilization, inform, questions, post exposure instructions
charting
a form of written communication done by the treatment team about the patient
rules of documentation
must be accurate, spelled correctly, concise, complete, factual and well arranged
charting rules
has to be in black or blue ink
correct patient
proper spelling and grammar,
military time, one approved abbreviations
neat
documented properly
date and time
put a date and time on every entry
military time
signature
identify who wrote what
error to documented chart
draw a single line, write mistaken entry, sign and date correction
if using paper chart
never tamper with handwritten notes, do not write over previous entries, do not change numbers left to right or vice versa
important parts of the patient charts to RT’s
history and physical
physician/nurse practitioner orders
hall pass
informed consent
advance directive
radiology procedure report
H & P
only tell condition of time of admission
who can write orders
doctor/physician (MD or DO), medical resident, nurse practitioner
orders
good for up to 14 months at RH
RH orders
all patients order should be viewed in EPIC, if ordering physician is not the same as the person who entered the order , it must be authorized by the MD, RNs, PA and nurse practitioners can place orders
Hall pass/ “hand off” communication/ SBAR
should include the patients name, date and time
lists the patients name and phone number of caregiver
person receiving chart needs to validate hall pass
situation
what is going on with the patients
background
what is the clinical background or context
assessment
anticipated changes in condition/ what do I think the problem is ?
recommendation
what would I do to correct the problem?
universal protocol
a standard procedure with multiple checks utilized within the admission/assessment process to minimize the risk of wrong sit, wrong procedure and wrong patient surgery
body mechanics
moving, lifting, positioning and handling patients and equipment safely is known as body mechanics
base of support
standing with the feet and the space between the between
center of gravity
sacral level 2
mobility muscles
found in the limbs= use for lifting
stability muscles
found in the torso= use for support
when transferring patients…
always ask the patients if they can independently do the transfer
let the patient do as much as possible
check the chart
be productive with certain diagnosis
inform the patient of what you are doing and list your steps out
rules for safe patient transfer
stand with feet apart
patient center of gravity should be held close to transferee’s center of gravity
use transfer belt if available
keep back stationary and let legs do the lifting
no twisting
beware of orthostatic hypotenstion
dizziness, fainting, blurred vision and slurred speech
patient should stand slowly
talk throughout transfer
wheelchair transfers
standby assist
assisted standing pivot
two person lift
hydraulic lift
things to remember
make sure his or her feet are properly covered for support
always transfer to the patients strong side
brakes are locked
footrest removed or folded
always let the patient known what you’re going to do or need them to do
standby assist
used for patient who have the ability to transfer from a wheelchair to a table on their own
WHEELCHAIR AT 45 DEGREES away from table
assisted standing pivot transfer
for patients who cannot transfer independently but can bear weight on their legs a standing pivot technique is used
wheelchair at 45 degrees angle
two person lift
used on patients who are lightweight and cannot bear weight on their lower extremities
stretchers
aka sheet transfer, three carrier lift and litter
when moving a patient
try to avoid tearing the patient skin
be aware of IV tubing, oxygen tubing, urine bags, catheters and draining devices
have patient cross arms over her chest during transfer
log roll
a technique used to turn patient whole body when it must be kept in a straight alignment at all times
what is a fall
falls are the most common hospital accident
an unplanned, sudden decent to the floor
without or with injury
most prone to falling
elderly, frail, sensory deprivation, medicated
routine application of immobilizations
positioning sponges
stability bar
velcro straps/restraints
sandbags
heel clamps
restraints
a physical restraint is any manual method or physical or mechanical device, material, or equipment attached to or adjacent to the residents body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body
soft limb restraints can also be used
must be able to put a finger in
