Unit 1 Lesson 1 & 2 Flashcards
Abbreviation for lactate ringers
LR
Abbreviation for 5% Dextrose in Water
D5/W
Sodium
Na
Drops
Gtt
Venipuncture
VP
Pounds per square inch
Psi
Potassium chloride
KCl
Measure of acidity
pH
Intravenous Piggy Back
IVPB
Chloride
Cl
The essential components of an Unusual Occurrence or Variance Report ,also known as an Incident Report, include:
Factual description of the event, physician notification, and outcome
What is the threefold purpose of documenting the nursing care provided?
Creating a legal record of the care provided, communicating pt status, and obtaining reimbursement for services
What form of documentation is composed of a story format?
Narrative
What documentary forms are used to document IV therapy procedures performed?
Nurse’s notes
Why should the word units be written out and not abbreviated as U?
It might accidently be read as zero
Ex. Of a subjective statement that is considered a common documentation error.
IV is dripping well
What charting formats tends to lead to greater opportunities for subjective rather than objective entries?
Narrative
The purpose of an unusual occurrence or variance report (incident report) is to
Provide factual, non judgmental accounts of unusual situations and their consequences
What are the 5 W’s?
-Who performed the procedure?
-What was done?
-When was it done?
-Where was it done?
-Why was it done?
SOAPIE (Documentation Format)
-Subjective
-Objective
-Assessment
-Plan
-Intervention
-Evaluation
Subjective
What the pt says
Objective
What you observe
Assessment
What you think is occurring
Plan
What you are going to do
Intervention
action taken
Evaluation
result achieved by the intervention.
PIE (Documentation Format)
-problem
-intervention
-evaluation
Focus Charting
method of organizing the narrative documentation
What forms are commonly used for IV therapy procedures?
Nurses notes, IV Flow Sheet, MAR, blood transfusion administration record
What abbreviation should never be used?
KVO
cath
catheter
CV
central venous
CVP
central venous pressure
D5/NS or D5NS
dextrose 5% in normal saline
fancy U symbol
micron
mcgtt
micro drop
NS
normal saline
ONC
over the needle catheter
TPN
total parenteral nutrition
VP
venipuncture
KO, KVO, or TKO
keep vein open (usually 5-10 cc)
Purpose of the venous access and intravenous infusion modalities is to:
Prepare LPNs for limited IV fluid treatment therapy
Tort
Legally, a private wrong, by act or omission, that can result in a civil action by the harmed person
IV Fluid therapy procedures; universal precautions are federally mandated by:
OSHA
IV therapy activities that may be delegated to the LPN:
initiating peripheral access, converting an IV cannula to a “locked” cannula, and monitoring blood transfusions
IV- LPN restricted from performing:
adding vitamins to TPN solution in home care setting
