Activities and Roles

Question 1

admission orders

Answer 1

Initial written directives by the doctor for the care and treatment of the patient.

Question 2

What are 9 common components of an admission order?

Answer 2

1. Admitting diagnosis
2. Diet order
3. Activity order
4. Diagnostic tests/procedures order
5. Nursing observation order
6. Medication order
7. Treatment order
8. Patient code status order
9. Miscellaneous order

Question 3

What is an admitting diagnosis?

Answer 3

The diagnosis provided by the physician at the time of admission which describes the patient’s condition upon admission to the hospital.

Since the Admitting Diagnosis is formulated before all tests and examinations are complete, it may be stated in the form of a problem or symptom and it may differ from any of the final diagnoses recorded in the medical record.

Question 4

What is a diet order?

Answer 4

A doctor’s order that states the type and quantity of food and liquids the patient may receive

Question 5

What is an activity order?

Answer 5

A doctor’s order that defines the type and amount of activity a hospitalized patient may have

Question 6

What is a diagnostic test/procedures order?

Answer 6

Tests ordered and performed for the evaluation of a prescribed treatment

Question 7

What is a nursing observation order?

Answer 7

A doctor’s order that requests the nursing staff to observe and record certain patient signs and symptoms

Question 8

What is a medication order?

Answer 8

a written order by a physician, dentist, nurse practitioner, or other designated health professional for a medication to be dispensed by a pharmacy for administration to a patient.

Usually medications are needed for the patient’s disease condition, for sleeping and for pain, nausea & vomiting

Question 9

What is a treatment order?

Answer 9

A nursing treatment order is any act performed by a nurse that implements the nursing care plan or any specific objective of the clinical plan or pathway

Question 10

What is a patient code status order?

Answer 10

Refers to the patient’s wishes regarding resuscitation

Question 11

What is a miscellaneous order?

Answer 11

Miscellaneous requests not covered in the common components

Question 12

activity order

Answer 12

Refers to the amount of walking, sitting and other motions that the patient may do in a given period during his or her hospital stay.

Activity changes are ordered to coincide with the patient’s stages of recovery.

Question 13

CBR

Answer 13

complete bed rest

Question 14

BR c̅ BRP

Answer 14

bedrest with bathroom privileges

Question 15

dangle

Answer 15

The patient may sit and dangle his/her feet over the edge of the bed

Question 16

Up in chair c̅ assist

Answer 16

The patient may sit in a chair with the assistance of a member of the nursing staff

Question 17

BRP when A & O

Answer 17

the patient may use the bathroom as desired when alert and oriented

Question 18

up in hall

Answer 18

the patient may walk in the hall

Question 19

up as tol

Answer 19

the patient may be out of bed as much as he or she can physically tolerate

Question 20

up ad lib

Answer 20

the patient has no restrictions on activity

Question 21

OOB

Answer 21

the patient may be out of bed

Question 22

Amb.

Answer 22

the patient must ambulate (walk) for prescribed periods of time

Question 23

Walk c̅ assistance

Answer 23

physio or RN will assist patient to walk

Question 24

AAT

Answer 24

activity as tolerated

Question 25

What is the 4 roles of Nutrition Services?

Answer 25

1. To meet the therapeutic needs and dietary preferences of the patient. 2. Preparing and serving food for patients. 3. To aid in development and monitoring of special therapeutic diets. 4. Providing dietary information to patients

Question 26

What is a diet order?

Answer 26

A doctor’s order that states the type and quantity of food and liquids the patient may receive

Question 27

regular / general

Answer 27

for patients who have no dietary restrictions

Question 28

GI soft

Answer 28

for patients with nausea and distention, usually post surgical patient

Question 29

mechanical soft

Answer 29

for patients who have trouble chewing or swallowing

Question 30

pureed / minced

Answer 30

for patients with problems chewing and swallowing, ex. no dentures

Question 31

no thin liquids / thick fluids only

Answer 31

to prevent choking

Question 32

diabetic diet

Answer 32

for patients who cannot produce enough insulin

Question 33

renal diet

Answer 33

for patients with renal disease

Question 34

neutropenic

Answer 34

to reduce the number of bacteria entering the stomach for patients on chemotherapy or those with immune deficiency diseases

Question 35

lactose controlled

Answer 35

for patients who experience stomach disturbances after drinking/eating products containing milk

Question 36

nothing by mouth (NPO)

Answer 36

for patients pre & post surgery, scheduled for procedures, tests or as indicated

Question 37

clear fluids

Answer 37

for patients whose digestive system should not or cannot digest whole foods. Ex. Pre and post surgery

Question 38

full fluids

Answer 38

for patients who cannot eat solid foods

Question 39

cardiac diet

Answer 39

low sodium, no sugar, low cholesterol

Question 40

controlled sodium

Answer 40

for patients with heart disease, high blood pressure, kidney disease, or may be using certain drugs ex. 2 gm NA or NAS

Question 41

controlled calorie

Answer 41

Limited caloric intake ex. 1,400 calorie reduced diet

Question 42

tube feed

Answer 42

for patients who must be fed by GI or NG tube ex. Isosource 50-100 cc q2h

Question 43

dysphagia / thickened

Answer 43

thickened fluids for a patient with swallowing difficulties

Question 44

DAT

Answer 44

allows the nursing staff to advance patients diet as tolerated without phoning the Doctor for a new order may start as CF – General tray Will not always notate "DAT" on PO

Question 45

What are 5 miscellaneous diet orders?

Answer 45

1. Hold tray / early tray / late tray 2. Fluid restrictions 3. Push or force fluids 4. Natural laxatives 5. Calorie count

Question 46

hold tray / early tray / late tray

Answer 46

for patients going to or returning from OR, tests, or treatments

Question 47

fluid restrictions

Answer 47

patients retaining fluids in tissues (edema)

Question 48

push or force fluids

Answer 48

patients are dehydrated and require additional juices, tea, etc.

Question 49

natural laxatives

Answer 49

bran, fruitlax, etc. ordered by doctor

Question 50

calorie count

Answer 50

a 24-hour calorie count record, RN records each item patient has eaten on the calorie count sheet

Question 51

Who can receive a snack between meals?

Answer 51

Patients on a special diet can receive a snack (not a meal) between meals. Delivered to the unit and given to the patient by the RN

Question 52

Who can receive a bedtime snack?

Answer 52

Diabetic patients

Question 53

Where can you get a bottle of water for a patient?

Answer 53

Stocked in the ward. Supplied by Food and Nutrition Services

Question 54

What food supplies can the NUC order to keep in the ward?

Answer 54

- juice - bread - butter - jell-o - ice cream - milk - sugar - cheese - crackers - ginger ale - popsicles - peanut butter - jam etc

Question 55

For training purposes, what are the routine blood draw times?

Answer 55

- 0700 - 0900 - 1100 - 1300 - 1500 - 1700 - 1900

Question 56

STAT blood orders follow the routine blood draw times, true or false?

Answer 56

false