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
ACUTE pain
discomfort for short duration
CHRONIC pain
Discomfort that last longer than 6 months
What should be included in the pain assessment
Onset Quality Intensity Location Duration
What are the tools you can use to assess pain?
Nemeric Scale
Word Scale
Linear Scale
Visual Analogy
Patient Controlled Analgesia
Intervention that allows client to self administrate opioid pain medication through use of an infusion device
What are some Nonpharmacologic ways to control pain
Education Imagery Distraction Relaxation Tech. Apply hot or cold Meditation Transcutaneous Eletrical Nerve Stimulation (TENS) Acupuncture Percutaneous Electrial Nerve Stin (PENS) Bio feedback Hypnosis
What is a placebo
Imitation of a drug
Admission
Physicians admit patients to facility. Billing information through admission department Medical history and physical Medical orders Scheduled Admission Emergency Admission Patient I.D. Bracelet
Nursing Admission
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
Common Response to Admission
Anxiety
Loneliness
Decreased privacy
Loss of identity
what is this considered? Safeguarding Valuables and clothing Helping the patient undress Compiling the data base Medical admission responsibilities Common responses to admission
Admission
Discharge Process
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
Leaving Against Medical Advice
Patient leaves before MD discharges When the patient is unhappy Try to negotiate Have patient sign AMA form Document
Discharge Planning
Improves client outcomes
Post discharge needs
Coordinating community resources
Special considerations
Discharge Instructions
Teaching (METHOD) page 170
Prescriptions
Appointments
Summary of discharge orders
Gathering belongings Arranging Transportation Escorting the Client Writing a discharge summary Terminal cleaning .........This is a process of
Discharging the patient
Transferring
Transfer activities Extended Care Facilities Skilled Nursing Facilities Intermediate Care Facilities Basic Care Facilities Nursing Homes Referrals Home health care
METHOD
Medacation Envioroment Treatments Health Teaching Outpatient Referal Diet
Gate control theory
1 message at a time
Endogenous opioids
Natural like morphine, its substances that your body produces.
What are the natural things your body produces that act like morphine
Endorphins
Dynorphins
Enkepalins
Cutaneous Pain
Orginates at the skin
Dermis Level
Pain localized
Subcanteous Level
Tissiue injuries, produces aching pain
Somatic Pain
Discomfort generated from deeper connective tissue
Reffered Pain
Poorly localized: discomfort in a general area
When do you assess pain?
When pt is addmited
When taking vital signs
at res/ during activity
b4 and after treatmet ( 20 min after)
JACHO
requires evidence that psin of termanially ill is being proprly treated
Opioid
Morphine
Codeine
Meperdine
Funtanyl
Non opioid
Tylenol, Motrin, Advil
Adjuvant Drugs
drugs that assist in accomplishing the desired effect of a primary drug
Rhizotomy
Surgical Sectioning of a nerve route close to spinal cord
Cordotomy
Intruption of pain pathway in spinal cord
