Unit 3 (CHAPTERS 9, 11, 20) Flashcards

1
Q

What is a medical record?

A

A collection of information about a persons health, the care provided by health care workers, and the clients process.

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2
Q

What is the medical record used for?

A

Share information for health care providers, thus ensuring client safety and countinity of care.

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3
Q

Who has access to the medical record?

A

All personal involved in a persons health care, including the person

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4
Q

Narrative charting

A

The cycle of documentation generally used in source orianted records. WRITTING INFORMATION IN CHRONOLOGICAL ORDER.

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5
Q

Computerized Charting

A

Documenting client information via the computer.

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6
Q

How do we protect health information?

A

HIPPA

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7
Q

Can nurses use abbreviations?

A

ONLY abberviations on agency approved list.

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8
Q

Change of Shift Reports

A
  • A discussion between a nursing spokeperson from the shift thats ending and arriving.
  • Summary of each Pts conditions and current status of care.
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9
Q

What do we say when we answer the phone?

A
  • 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
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10
Q

Pain

A

Unpleasent sensation usually associated with a diease or injury
5th vital sign

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11
Q

Process of pain

Time To Prepare Mentally

A

Transduction
Transmission
Pereception
Modulation

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12
Q

Transduction

A

Chemical information at the cellular level into eletrical impulses the move toward the spinal cord.

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13
Q

Transmission

A

Stimuli move from the perpheral nervous system toward the brain.

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14
Q

Perception

A

The concious exeprience of discomfort

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15
Q

Pain Threshold

A
  • The point at which sufficient pain transmitting stimuli reach the brain
  • each person’s threshold is the same
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16
Q

Pain Tolerance

A
  • The amount of pain a person handle.

- Diffrent for everbody

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17
Q

Modulation

A

Last phase of impulse transmission during which the brain with spinal nerves in downward fashion to subsquently after the pain.

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18
Q

Pain Theories

A
Specificity theory
Pattern Theory
Gate Control Theory
Nueroma Trix Theory
Endogenous Opioid Theory
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19
Q

Types of Pain

A
Cutaneous
Ursceral
Neuropathic
Acute
Chronic
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20
Q

Visceral Pain

A

Discomfort arising from Internal Organ

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21
Q

Neuopathic Pain

A

Pain w/ atypical characteristics

Happens up to days months or weeks after sourse of pain is resolved leg amputation

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22
Q

ACUTE pain

A

discomfort for short duration

23
Q

CHRONIC pain

A

Discomfort that last longer than 6 months

24
Q

What should be included in the pain assessment

A
Onset
Quality
Intensity
Location
Duration
25
Q

What are the tools you can use to assess pain?

A

Nemeric Scale
Word Scale
Linear Scale
Visual Analogy

26
Q

Patient Controlled Analgesia

A

Intervention that allows client to self administrate opioid pain medication through use of an infusion device

27
Q

What are some Nonpharmacologic ways to control pain

A
Education
Imagery
Distraction
Relaxation Tech.
Apply hot or cold
Meditation
Transcutaneous Eletrical Nerve Stimulation (TENS)
Acupuncture
Percutaneous Electrial Nerve Stin (PENS)
Bio feedback
Hypnosis
28
Q

What is a placebo

A

Imitation of a drug

29
Q

Admission

A
Physicians admit patients to facility.
Billing information through admission department
Medical history and physical
Medical orders
Scheduled Admission
Emergency Admission
Patient I.D. Bracelet
30
Q

Nursing Admission

A
Prepare room
Welcome patient
Orient patient
   Location of nurses station
   Bathroom
   Personal storage
   How to call nurse
   How to adjust bed
   Lights
   Telephone
   TV
   Daily routine- meal times
   When the MD makes rounds
   Scheduled tests/surgery
31
Q

Common Response to Admission

A

Anxiety
Loneliness
Decreased privacy
Loss of identity

32
Q
what is this considered?
Safeguarding Valuables and clothing
Helping the patient undress
Compiling the data base
Medical admission responsibilities
Common responses to admission
A

Admission

33
Q

Discharge Process

A

Termination of care from a health care facility.
Discharge begins at admission
Written orders for discharge
Give discharge instructions
Notify business office
Write a summary of condition at discharge
Request room to be cleaned

34
Q

Leaving Against Medical Advice

A
Patient leaves before MD discharges
When the patient is unhappy
Try to negotiate
Have patient sign AMA form
Document
35
Q

Discharge Planning

A

Improves client outcomes
Post discharge needs
Coordinating community resources
Special considerations

36
Q

Discharge Instructions

A

Teaching (METHOD) page 170
Prescriptions
Appointments
Summary of discharge orders

37
Q
Gathering belongings
Arranging Transportation
Escorting the Client
Writing a discharge summary
Terminal cleaning
.........This is a process of
A

Discharging the patient

38
Q

Transferring

A
Transfer activities
Extended Care Facilities
Skilled Nursing Facilities
Intermediate Care Facilities
Basic Care Facilities
Nursing Homes
Referrals
Home health care
39
Q

METHOD

A
Medacation
Envioroment
Treatments
Health Teaching
Outpatient Referal
Diet
40
Q

Gate control theory

A

1 message at a time

41
Q

Endogenous opioids

A

Natural like morphine, its substances that your body produces.

42
Q

What are the natural things your body produces that act like morphine

A

Endorphins
Dynorphins
Enkepalins

43
Q

Cutaneous Pain

A

Orginates at the skin

44
Q

Dermis Level

A

Pain localized

45
Q

Subcanteous Level

A

Tissiue injuries, produces aching pain

46
Q

Somatic Pain

A

Discomfort generated from deeper connective tissue

47
Q

Reffered Pain

A

Poorly localized: discomfort in a general area

48
Q

When do you assess pain?

A

When pt is addmited
When taking vital signs
at res/ during activity
b4 and after treatmet ( 20 min after)

49
Q

JACHO

A

requires evidence that psin of termanially ill is being proprly treated

50
Q

Opioid

A

Morphine
Codeine
Meperdine
Funtanyl

51
Q

Non opioid

A

Tylenol, Motrin, Advil

52
Q

Adjuvant Drugs

A

drugs that assist in accomplishing the desired effect of a primary drug

53
Q

Rhizotomy

A

Surgical Sectioning of a nerve route close to spinal cord

54
Q

Cordotomy

A

Intruption of pain pathway in spinal cord