Week Fourteen Flashcards
What is a contagion check?
Information that is gathered at the time of admission about the client’s immunization history, recent exposure to communicable diseases, history of communicable diseases, and current signs of any illness
What is the rationale of a contagion check?
identify possible sources of contagious diseases so measures can be taken to prevent its spread, identify children/adults who require recommended immunizations
What are reasons for a transfer?
condition changing, treatments, need to go to a different floor or facility
Define Risk for Latex Allergy Response
At risk for allergic response to natural rubber latex products
Risks factors for Risk for Latex Allergy Response
children with three or more surgeries, professions with daily exposures to latex, hairdressers, janitors, allergies to bananas, apples, carrots, history or asthma, history of allergies
AMA Discharge
Against Medical Advice. Attempt to determine why client wants to leave, notify nursing supervisor and client’s MD, client signs appropriate forms (if they won’t sign, document and have witness), assist client to get ready and escort them to the door
What will the RN teach the client during the admission process?
facility processes/healthcare team members, condition or medication management, NUR care plan, possible discharge scenarios
Why should the RN pay attention to the client condition prior to initiating any admission procedures?
address basic needs according to maslow, establish nurse-client relationship, modifications, wellness, age, culture, database
What client information should be obtained during the admission process?
biographical data, chief complaint, history of present illness, past medical history, past surgical history, allergies, immunizations, medications, family history, support system, physical assessment, functional abilities, discharge needs
What does the RN need to do to complete the admission process?
orient client to routines and environment, client teaching, discharge planning, collect ordered specimens, initiate nursing care plan and nursing process, document and report
What is the RN’s responsibility in the transfer of a client?
facilitating interdisciplinary collaboration and ongoing communication, being a client advocate, identify and help the client to access resources necessary to support recovery or maintain health, reduce client and family stress by teaching them what to expect
Transferring within an agency
explain reason for transfer, don’t forget to transfer belongings, send original chart, make transportation arrangements
Transferring outside of agency
pack all belongings, send copy of chart, report
Receiving a transfer within an agency
obtain report, may need orientation to new unit, review chart, document time of arrival and condition of client
Receiving a transfer from outside agency
implement usual admission procedure, review information sent with the client
Receiving telephone report
document date/time of call, document name and credentials of caller, accurately document information reported, sign note with name and title, if you are receiving report, repeat the information back to send to ensure clarity
Giving telephone report
be concise and accurate with report, begin with name, title and relationship to client, include client name and medical diagnosis, report changes in nursing assessment, report current VS and baseline VS, report significant lab values, report TNI and client response, after giving telephone report, document date, time, and content of call, signature and title
When does discharge planning begin?
on admission
What is continuity of care?
the coordination of health care services by healthcare providers for clients moving from one healthcare setting to another and between and among healthcare professionals
What is the RN’s role in the continuity of care
initiate discharge planning upon admission, involve client and family or support persons, collaborate with healthcare professionals
What are the essential components of discharge planning?
review why client was admitted, maintain ongoing assessment of client, assess client and caregiver needs at time of discharge, determine interdisciplinary needs, encourage client and support person participation, review discharge teaching with client and/or support person, written discharge instructions given to client and/or support person
What should discharge instructions include?
list of all medications to be taken, treatments/procedures, dietary and activity order, health promotion strategies, referrals, when to call MD and proper phone number, follow-up appointment and dates
What should the RN’s checklist or discharge summary include?
description of client’s physical, mental, and emotional status, resolved health problems, unresolved or continuing health problems and needs, treatments to continue, medications, restrictions, functional abilities, comfort level, support networks, client education provided at time or discharge, discharge destination and who accompanied client, referral services, follow-up
Intravenous Therapy
Method of supplying fluids and electrolytes directly into the intravascular fluid compartment
