Working in Hospital Flashcards
What is an elective admission to the hospital
admittance to hospital for elective surgery/procedure
- substance abuse txt
- psychiatric
- planned surgeries
- non-emergent
- preg/child birth
What are requirements for elective admission to hospital
1-2 weeks before admit
complete history and physical
tests for anesthesia
What is a non-elective admission to the hospital
admittance to hospital for txt of acute problem
- MI
- stroke
- COPD
- trauma
- appendicitis
- GI bleeding
What are requirements for non-elective admission to hospital
complete H&P within 24 hrs
admitting orders
- instructions to hospital staff on how want pt cared for
How to write hospital admission orders
Admit (provider, unit or floor)
Diagnosis (reason for admitting)
Condition (subjective listing stable, guarded, critical)
Activity (permitted activities)
Vital signs (continuous, q shift)
Allergies
Diet (regular, NPO, diabetic)
Interventions (PT, OT, RT, IV)
Medications (name, dose, route, freq, duration)
Procedures (wound care, dressing changes, ostomy care)
Labs (xray, ekg, labs)
Special instructions (when to notify the provider and other info)
What are verbal orders used for
urgent or emergent situations
all meds should be stated and spelled out
should be converted to verbal orders ASAP
What is closed loop communication
Indiv receiving the verbal order reads back the order to the presenter
What is anesthetic risk
Used by anesthesiologists
Class I - healthy 24 hours
E = emergency surgery (doubles risk)
48 hour mortality class V - 8.1% and Class 1 - 0.07%
What is pre-op evaluation
Used to determine if pt able to have surgery
What are predictors of risk for surgery
Major (CHF, vascular diseases)
Intermediate (Prior MI or CHF)
Minor (age, low functional capacity, Uncontrolled blood pressure)
What is on template for pre-operative assessment and recommendations
Surgery planned
History of presenting illness
medications
ROS
vital signs and focused examinations
impression, recommendations and plan
Tests
- hematocrit (>60, anticipate blood loss)
- electrolytes (>60, DM, renal/liver dx, diuretics)
- urinalysis (only if getting prosthetic joint)
- protime & PTT (liver dx, anticoag pt, malignancy)
- chest radiograph (>60, card and pulm disorders)
- electrocardiogram (M > 40, W > 50, DM, heart dx)
What does the peri-operative patient safety phase cover
- inform pt so can make good surgical decision
- uncover preventable situations
- get a signed surgical consent
- talk to pt before medicated
- excellent team communication throughout care process
what is done during peri-operative safety phase
Before pt goes OR - signed consent - H&P - anesethia visit - surgical site marking In OR - proper positioning/securing on table - verify patient, surgical site, allergies - instrument counts Before incision - surgical time-out Post op instrument counts
What is put in procedure notes
name of procedure indication for procedure consent (with risk, benefits, complications) anesthesia details operation findings complications estimated blood loss
what is put in full operative report
Date of procedure Name of procedure Indication: reason for the procedure Surgeon Surgical assistant(s) Anesthesia Pre-op presumptive diagnosis Post-op diagnosis Descriptions: Specimens Estimated blood loss (EBL) Drains Complications Disposition
