Term
| Which healthcare providers in the Air Force medical facilities are authorized to both treat and admit pt's? |
|
Definition
| Dentists, physicians, and Certified nurising midwives |
|
|
Term
| Who is responsible for notifying the inpatient unit that a routine pt is being admitted? |
|
Definition
| The physician or the physician's designated representative |
|
|
Term
| What is the basic difference between a routine admission and a direct or newborn admission? |
|
Definition
| The order in which various procedures are carried out |
|
|
Term
| What two factors determine where the pt goes after finishing with the admissions and dispositions office? |
|
Definition
| the condition of the pt, and facility policy |
|
|
Term
| Whare are two advantages of preadmissions? |
|
Definition
| it cuts down on both pt waiting time and frustration |
|
|
Term
| When should you begin to assemble the inpatient record? |
|
Definition
| immmediately following notification that you are getting a pt |
|
|
Term
| What are your responsibilities concerning the inpatient record when there are no 4A's assigned to your floor? |
|
Definition
| you need to know what paperwork is required and how to fill it out |
|
|
Term
| What items whould you bring to the bedside of a newly admitted pt? |
|
Definition
| bed pan, urinal, gown, slippers, water pitcher, cup, wash cltoh, wash basin, emesis basin, and if necessary...IV pole and urine specimen cup |
|
|
Term
| Normally what admission procedures are done by the admissions nurse and tech? |
|
Definition
| pt assessment, pt history, VS, height and weight |
|
|
Term
| Where should you place the call bell? |
|
Definition
| Attached to the bed within reach of the pt |
|
|
Term
| What info should you cover when orienting the pt and family to your unit? |
|
Definition
| Visiting hours, day room rules, meal times, bathrooms, call bells, VS times, names of care providers, sign in and sign out procedures |
|
|
Term
| What aspects of inpatient unit routines should you explain to the pt? |
|
Definition
| anything that affects the pt |
|
|
Term
| What two methods are used in inpatient units to help monitor the location of pt's |
|
Definition
| pt status board, sign out log |
|
|
Term
| What is the purpose of a pt pass? |
|
Definition
| allow the pt to leave for short time...usually 24-48 hours |
|
|
Term
| Who is the approval authority for pt passes? |
|
Definition
|
|
Term
| Who is immediately notified when a pt does not return from a pass? |
|
Definition
|
|
Term
| What is the purpose of convalescent leave? |
|
Definition
| To allow non-chargeable leave for recovery purposes |
|
|
Term
| What is an interservice transfer and when is it used? |
|
Definition
| a transfer between services withouth physically moving the pt, used when the physician decides the pt needs special care |
|
|
Term
| Who approves a medical facility transfer? |
|
Definition
|
|
Term
| Who is responsible for the preparation of the pt's records for AE? |
|
Definition
|
|
Term
| How are paraplegic pt's transferred during AE? |
|
Definition
|
|
Term
| What is the weight limit for pt's baggage during AE? |
|
Definition
|
|
Term
| What are the three types of dispositions? |
|
Definition
| transfer, subsisting elsewhere, discharge |
|
|
Term
| What info is included in the nurse's discharge note? |
|
Definition
| pt condition, final treatments, and discharge instructions |
|
|
Term
| What AFI provides a list of forms to be assembled after the discharge of a pt? |
|
Definition
|
|
Term
| What is the last office to be cleared by a pt when discharged? |
|
Definition
|
|
Term
| What info must be on the pt's inpatient record? |
|
Definition
| at minimum the pt's name, ssn, admission registration #, and MTF name |
|
|
Term
| What form is used to record intake and output? |
|
Definition
| DD form 792 intake and output record |
|
|
Term
| What should be documented on the output intake form when starting an IV? |
|
Definition
| Fluid, date and time, amount started, rate, and meds in solution |
|
|
Term
| How many pounds are in one kilo? |
|
Definition
|
|
Term
| What type of pt may have daily abdominal girth measurements taken? |
|
Definition
| Cirrhosis of the liver, or possible internal bleeding |
|
|
Term
| Who is responsible for ensuring documentation guidelines are in place and followed? |
|
Definition
|
|
Term
| what soes SOAPP stand for? |
|
Definition
| subjective info, objective info, assessment, plan, and prevention |
|
|
Term
|
Definition
| Outcome oriented nursing documentation system |
|
|
Term
| What form does a provider use to document orders on a pt admitted to the hospital? |
|
Definition
| AF for 3066 Doctors orders form |
|
|
Term
| What are 2 uses for the AF form 3066? |
|
Definition
| transmit doctors orders to nurses and establish a drug profile on the pt |
|
|
Term
| How does the nurse indicate that the physician's order have been carried out? |
|
Definition
| writing "noted" on orders sheet |
|
|
Term
| What form or paperwork would you place on the front of a chart for a pt sheduled for surgery? |
|
Definition
| locally devised surgical checklist |
|
|
Term
| What are the 2 categories normally found on a surgical checklist? |
|
Definition
| clinical records and pt care procedures |
|
|
Term
| What is the OF 522 used for? |
|
Definition
| documenting pt consent for a procedure |
|
|
Term
| What should you do with a pt's labs and x-rays the morning of a surgery? |
|
Definition
| Determine if and which labs and x-rays will be needed in the surgery packet |
|
|
Term
| What actions should you take if your pt is wearing jewelry and he or she is going to surgery? |
|
Definition
| remove all jewelry and leave it with a family member or in a secure valuables vault |
|
|
Term
| What specific actions would you take if the a pt was scheduled for hand or arm surgery? |
|
Definition
| assure that all jewelry and bands are removed from both hands wrists or arms |
|
|
Term
| What do you do if there is a descrepancy between the pt's ID band and their surgical paperwork? |
|
Definition
| bring it to the attention of the nurse and fix it immediately |
|
|
Term
| What are nursing activities designed to do? |
|
Definition
| Help pt achieve nursing goals and objectives |
|
|
Term
| What are the 4 steps you use when you plan nusrsing care? |
|
Definition
| Make priorities, make goals, make objectives, select nursing activities |
|
|
Term
| How are pt problems and diagnoses prioritized? |
|
Definition
| according to the most lif-threatening problem |
|
|
Term
| What is a goal in terms of pt care? |
|
Definition
| an achievable statement of a change in pt behavior or condition |
|
|
Term
| Who should you consult with when you set priorities and establish goals? |
|
Definition
|
|
Term
| How do objectives relate to nursing goals? |
|
Definition
| objectives are daily steps towards achieving the goals |
|
|
Term
| Briefly describe the steps you follow to implement a nursing activity? |
|
Definition
| Check physicians orders, organize, wash hands, get equipment, ID pt, explain and do procedure, observe, clean up, wash hands, report and record |
|
|
Term
| What should you do if the nursing activity is unsuccessful? |
|
Definition
| figure out what when wrong and make a new plan |
|
|
Term
| what are the 3 major goals in the preoperative period? |
|
Definition
| prepare pt mentally physically and spiritually |
|
|
Term
| What nursing intervention can help to relieve most of the pt's concerns prior to surgery? |
|
Definition
| proper pt education and teaching |
|
|
