Unit 3 (CHAPTERS 9, 11, 20) Flashcards
What is a medical record?
A collection of information about a persons health, the care provided by health care workers, and the clients process.
What is the medical record used for?
Share information for health care providers, thus ensuring client safety and countinity of care.
Who has access to the medical record?
All personal involved in a persons health care, including the person
Narrative charting
The cycle of documentation generally used in source orianted records. WRITTING INFORMATION IN CHRONOLOGICAL ORDER.
Computerized Charting
Documenting client information via the computer.
How do we protect health information?
HIPPA
Can nurses use abbreviations?
ONLY abberviations on agency approved list.
Change of Shift Reports
- A discussion between a nursing spokeperson from the shift thats ending and arriving.
- Summary of each Pts conditions and current status of care.
What do we say when we answer the phone?
- Answer promptly
- Speak in a normal tone
- Identify yourself by name, title, and unit
- Obtain the reson for call
- Discretely identify the client
- converse in a courteous and buisness like manner
- repeat information to make sure its correct
Pain
Unpleasent sensation usually associated with a diease or injury
5th vital sign
Process of pain
Time To Prepare Mentally
Transduction
Transmission
Pereception
Modulation
Transduction
Chemical information at the cellular level into eletrical impulses the move toward the spinal cord.
Transmission
Stimuli move from the perpheral nervous system toward the brain.
Perception
The concious exeprience of discomfort
Pain Threshold
- The point at which sufficient pain transmitting stimuli reach the brain
- each person’s threshold is the same
Pain Tolerance
- The amount of pain a person handle.
- Diffrent for everbody
Modulation
Last phase of impulse transmission during which the brain with spinal nerves in downward fashion to subsquently after the pain.
Pain Theories
Specificity theory Pattern Theory Gate Control Theory Nueroma Trix Theory Endogenous Opioid Theory
Types of Pain
Cutaneous Ursceral Neuropathic Acute Chronic
Visceral Pain
Discomfort arising from Internal Organ
Neuopathic Pain
Pain w/ atypical characteristics
Happens up to days months or weeks after sourse of pain is resolved leg amputation