RLE: MIDTERM Flashcards
a report delivered to and by all nurses caring for a patient.
ENDORSEMENT
Gives the indication for admission or medical diagnosis to new clients. Include details on recent and actual changes to the client’s condition.
ENDORSEMENT
a legal document and may be used to provide evidence in court, many factors are considered in recording.
Client’s record
The purpose of endorsing is to communicate specific information to a person or group of people. A report, whether oral or written, should be concise, including pertinent information but no extraneous detail.
Goal of Change-of-Shift Reports
associated with sentinel events that will result in adverse health care outcomes or death
Incomplete handoff communication
I-SBAR
Introduction, Situation, Background, Assessment, Recommendation
PACE:
Patient/Problem, Assessment/Actions, Continuing (treatments)/Changes, Evaluation
Five-P’s:
Patient, Plan, Purpose, Problem, Precautions, Physician
Types of doctor’s order:
written
*verbal
*telephone
*electronic
*email, viber, telegram {social media apps}
communication tool used to convey the client’s current orders as well as upcoming tests or surgery, diet, etc quickly and briefly.
KARDEX
Is a desktop file system that gives a brief overview of each patient and is updated every shift. It is a reference for nurses that is separate from the patient’s chart.
KARDEX
Forms for Recording Data
Flow Sheets
Nurse’s Progress Notes
Discharge Summary
Use only RED BALL PEN
for end-to-end ticking of doctor’s orders. Underline the last phrase to signify the last entry.
as “ An Act Strengthening the Philippine Disaster Risk Reduction and Management System, Providing for the National Disaster Risk Reduction and Management Framework, Institutionalizing the National Disaster Risk Reduction and Management Plan, Appropriating Funds
Republic Act No. 10121
CODE RED
Firke
CODE blue
Adult emergency
Code white
Pediatric Medical Emergency
CODE PINK
Infant Abduction
Rapid Response System
CODE PURPLE
Bomb threat
CODE YELLOW
CODE GRAY
Combative Person
CODE SILVER
Person with a weapon and/or Active Shooter and or Hostage Situation
Hazardous Material Spill / Release
CODE ORANGE
CODE GREEN
Missing High Risk Patient
CODE BROWN
Earthquake
CODE TRIAGE- EMERGENCY ALERT
Limited activation of selected key personnel for potential incident
CODE TRIAGE- INTERNAL
Activate Emergency Operations Plan for Internal Incident
CODE TRIAGE- EXTERNAL
Activate Emergency Operations Plan for External Incident
Terminating an emergency code
When the incident response is complete
the appropriate authority (e.g Incident Commander, Team Leader, etc…) will call the emergency page operator and request that they announce an “All Clear.”
Originates on SA node
HR from 60-100 bpm
p waves similar
NSR
PROCESS OF ASSIGNING COMPETENT PEOPLE TO FULFILL THE ROLES DESIGNATED FOR THE ORGANIZATIONAL STRUCTURE.
STAFFING/NURSE STAFFING
APPROPRIATE NURSE STAFFING IS CRITICAL TO THE DELIVERY OF QUALITY, COST AND EFFECTIVE HEALTH CARE
CORE COMPONENTS OF NURSE STAFFING
FACTORS AFFECTING NURSE STAFFING
PATIENT ACUITY, COMPLEXITY OR STABILITY
NUMBER OF ADMISSIONS,DISCHARGE AND TRANSFERS
STAFF SKILL MIX AND EXPERTISE
PHYSICAL LAYOUT OF THE NURSING UNIT
AVAILABILITY OF TECHNOLOGY AND OTHER RESOURCES
A PLAN THAT ARTICULATE, HOW MANY HOURS AND WHAT KIND OF STAFF ARE NEEDED PER SHIFT OR PER DAY IN THE UNIT OR IN A DEPARTMENT.
NURSE STAFFING PATTERN
2 WAYS OF DEVELOPING A STAFFING PATTERN
DETERMINE THE NUMBER OF NURSING CARE HOURS NEEDED /PATIENT.
DETERMINE THE NURSE-PATIENT RATIO IN PROVIDING NURSING CARE
TIMELINE TABLE SHOWING PLANNED WORK DAYS AND SHIFTS FOR NURSING PERSONNEL
SCHEDULING
ISSUUES TO CONSIDER IN SCHEDULING STAFF
PENS
PATIENT TIME AND ACUITY
NUMBER OF PATIENT
EXPERIENCE OF STAFF
SUPPORT AVAILABLE TO THE STAFF
SCHEDULING
40 HOUR WEEK LAW – Based on
RA 5901
Identifying the components the nursing care and nursing service
PROJECTING STAFFING NEEDS
A METHOD OF GROUPING PATIENTS ACCORDING TO THE AMOUNT AND COMPLEXITY OF THEIR NURSING REQUIREMENTS AND THE NURSING TIME AND SKILLS THEY REQUIRE.
Patient Care Classification
The patient is ambulatory and can do activities of daily living without the help of a nursing personnel.
CATEGORY I. Self-care/Minimal Care
Patient who may have disturbance in the level of consciousness and / or debilitating conditions and may need complete care for the performance of activities of daily living.
CATEGORY III. Maximum Care
Patient is ambulatory but by reason of disability or therapeutic management, he may need assistance from a nursing personnel to do activities of daily living.
CATEGORY II. Moderate Care
Post fractional or diagnostic dilatation and curretage
example of?
CATEGORY II. Moderate Care
Gyne patients on chemotherapy,
Post partum profuse bleeding
example of?
CATEGORY III. Maximum Care
Patient who may or who may not have disturbance in the level of consciousness but may have restrictions in activities brought by diseases and may need complete care for the performance of the activities of daily living.
CATEGORY IV. Intensive Care
Patient with Myocardial Infarction,
Post ICCU patient,
CATEGORY IV. Intensive Care
Emergency Room
Step 1
DETERMINE THE LEVEL OF CARE
Emergency Room
Step 2
COMPUTING THE NCH/Day
COMPUTING THE NCH/Year
what step in ER?
Emergency Room
Step 3
